No Known Drug Allergies
hypertension, hyperlipidemia, diabetes
Right knee arthroplasty at age 18 secondary to hockey injury
Newly divorced. Smokes 1PPD, Drinks 2 glasses of bourbon 5 days out of the week.
| Time | Provider | Notes |
|---|---|---|
| 0830 | Penny Potts M.D. | AAOx3, in bed. Patient was at company BBQ earlier and developed midsternal chest pain about 2 hours into the event. The pain became persistently worse. The patient left and picnic and presented to the ED. Patient reports this is the worst pain he has ever felt, and it had not gone away. The midsternal pain is 10/10, burning with associated nausea and retching, nonproductive. Nothing makes it better or worse. It stays in the midsternal. No referred pain. The patient admitted for chest pain work up and to rule out myocardial infarction. |
| Time | 0800 | |
|---|---|---|
| Heart Rate | 86 bpm | |
| Blood Pressure | 130/84 mmHg | |
| Respiratory Rate | 22 breaths/min | |
| Temperature | 98.4 F | |
| Pulse Oximetry | 97% | |
| Oxygen in Liters | Room Air | |
| Pain | 7/10 |