No Known Drug Allergies
History of cocaine misuse, PTSD
Denies
Vapes, Drinks etoh daily, and smokes marijuana
| Time | Provider | Notes |
|---|---|---|
| 0830 | Michael Stark, M.D. | AAOx4, in bed. Patient reports onset of pain a few hours ago when they were relaxing on the couch and suddenly developed chest pain. Rates pain 10/10, sharp and throbbing, mid-sternum, no associated symptoms, nothing makes it better, and exertion makes it worse. Work up for chest pain, rule out myocardial infarction. |
| Time | 0800 | |
|---|---|---|
| Heart Rate | 120 bpm | |
| Blood Pressure | 148/76 mmHg | |
| Respiratory Rate | 24 breaths/min | |
| Temperature | 98.5 F | |
| Pulse Oximetry | 96% | |
| Oxygen in Liters | Room Air | |
| Pain | 8/10 |