Example of Patient Chart Printout using daED™

Patient:  R Robinson, Jan 27, 2002, 10:25 pm, Originator:  Paul Marchand, MD, Page 1

Patient:  R Robinson, January 27, 2002, 10:25 pm

 CHIEF COMPLAINT

                Chest, chest pain

HPI

Patient is a 51-year-old male. Presented after 2 hr(s). History source:  Patient. Brought in by ambulance. Complains of pain:  Pain location chest – left, shoulder – left anterior, arm – upper left. Time course:  Gradual onset. Intermittent.  Still present. Improved. Not resolved. Similar symptom previously. Onset during mod./heavy activity. Residual arm discomfort (Left only). Duration each episode 20 min(s). Pain quality:  Dull.  Pressure. Tightness. Radiation:  (arm – upper left, antecubital – left, arm – lower left). Present at rest. Exertional. Worsened by:  Exertion. Not worsened by deep breath. Not worsened by change in position. Not worsened by movement. Not worsened by palpation. Relieved by:  Rest. Not relieved by position. Not relieved by antacids. Nitroglycerin (x2). Relief from oxygen: (transient). No loss of consciousness, Initial distress: moderate. Distress when seen in ED mild. No cough. Associated symptoms:  No fever. No chills. No sore throat. No hoarseness. No dyspnea on exertion. No paroxysmal nocturnal dyspnea. No palpitations. Headache. Chest pain. Diaphoresis. Numbness/tingling (antecubital – left, arm – lower left). No weakness.  Dizziness. Shortness of breath (can’t get enough air). Nausea. No abdominal pain. No vomiting. No diarrhea.

ROS

General

Shortness of breath (can’t get enough air).  No fever.  No chills.  No high blood pressure.  No diabetes.  Headache.  No weakness.  No dizziness.  No neck pain.  Numbness/tingling (antecubital – left, arm – lower left).  No paraesthesia.  No calf pain.  No pedal edema.

Eyes

ROS Eyes negative.  No eye problems in the past 6 weeks.  No changes in vision or eye pain noted.

Ears

ROS Ears negative.  No changes in hearing or ear pain. No abnormal sounds noted and no history of ear discharge.

Nose

ROS Nose negative. No nasal discharge or inflammation.  No history of allergic rhinitis.

Throat

ROS Throat negative. No history of throat infection within the last 3 months. No history of recurrent throat infection. No difficulty swallowing. No sore throat. No hoarseness.

Heart

See history of present illness for appropriate questions as review of systems.  Chest pain. No dyspnea.

Lungs

ROS Lungs negative. No history of chronic lung disease, reactive airway disorders, or shortness of breath. No cough. No dyspnea on exertion. No paraoxysmal nocturnal dyspnea.

G.I.

ROS G.I. negative. No history of chronic pain or food intolerance. No history of chronic diarrhea, nausea or vomiting.  Nausea. No vomiting. No diarrhea.

Urinary

ROS Urinary negative. No changes in usual urinary habits. No blood on urination. No painful urination.

Musculo-skeletal system

ROS Musculo-skeletal negative. No history of excessive weakness, chronic arthralgias or myalgias. No weakness.

Neuro Psychaitric

Headache. No change in vision. No psychiatric disorder. Numbness/tingling (antecubital – left, arm – lower left). No weakness. No history of alcohol intake. No history of drug abuse.

Patient:  R Robinson, Jan 27, 2002, 10:25 pm, Originator:  Paul Marchand, MD, Page 2

Skin

ROS Skin negative. No rash. No excessive puritis. No history of jaundice. No other disorders of the skin including chronic skin disease or irritation.

Immunological

ROS Immunological negative. No history of innunocompromised disease. No history of chronic recurrent infections.

Hematologic

ROS Hematololgic negative. No easy bruising or excessive bleeding from minor trauma.

Endocrine

ROS Endocrine negative. No unexplained weight loss or weight gain. No excessive thirst or urination. No history of heat or cold intolerance.

Past Med Hist

General

Old chart requested. Old chart reviewed. No medications. No known drug allergies. O/C drugs (tylenol).

Medical

No diabetes. No high blood pressure. No hyperlipidemia. No high cholesterol. No chronic pain. No cerebral vascular accident. No heart disease. No myocardial infarction. No cardiomyopathy. No prior thrombolytics. No asthma. No bronchitis. No lung disease. No tuberculosis. No pneumonia. No pulmonary embolus. No ulcers. No gallstones.  No history of liver disease. No gastroenteritis. No diverticulitis. No kidney disease. No disc disease. No bladder infection. No deep vein thrombosis. No cancer. No psychiatric illness. No panic disorder.

Surgical

No recent surgery. No recent trauma. No thrombolytics. Tonsilectomy. No history of heart surgery. No abdominal surgery. No appendectomy. Back surgery. Disc surgery.

Social

Married. Lives with spouse. Occupation: construction. Smoker (pack per day 1). Smoker for 30 yrs. Alcohol (2 drinks per day). No street drugs.

Fam Med Hist

Medical

Asthma. COPD. Heart disease. No gallstones. No liver disease. No kidney disease. No intestinal problems. High  blood pressure. No diabetes. No psychiatric illness.

Surgical

No gall bladder removal. Tonsilectomy. Coronary bypass.

P.E.

Appearance

Well nourished. Well hydrated. Athletic. Appears ill.  Level of consciousness:  Alert. No respiratory distress. Does not smell of alcohol. Vital signs:  Temp 98. Resp. rate 18. 02 sat.%100.02 supplement (by nasal prongs). 02 supplement at 2 liters/min. Supine vitals:  BP 120/88. Heart rate 96. Anxious. Distress (mild).

HEENT

Normal HEENT exam. Normalcephalic atraumatic. Pupils equal round and responsive to light and accommodation. Normal symmetric eye movements. EARS are normal externally and tympanic membranes are normal (without dullness or inflammation). NOSE is not deformed or inflamed. No nasal discharge noted.  MOUTH and THROAT are not inflamed and show no evidence of acute disease.

Neck

Normal neck exam. Neck is supple and without mass or bruit. Thyroid is normal on inspection and palpation.

Card. Vasc

Normal cardio vascular exam. Heart has a regular rate and rhythm. No murmurs, bruits, rubs, or gallop. No cyanosis: central or peripheral is noted. No edema and no jugular veinous distention is noted. No clubbing of nails. No cyanosis of nails. Peripheral edema: none.

Patient:  R Robinson, Jan 27, 2002, 10:25 pm, Originator:  Paul Marchand, MD, Page 3

Chest

Normal chest/lung exam. Chest is not deformed and breathing is symmetric and nonlabored. Lung sounds are clear with good air movement in all fields.

Abdomen

Normal abdominal exam. Bowel sounds soft nontender and without guarding or rebound. No mass is appreciated and there is no organomegaly.

Back Exam

Normal back exam. No deformation, no tenderness or palpation or percussion is noted.

Uro Gen

Normal uro-genital exam. Normal development for age and sex. Nontender and without discharge.

Musc. Skeletal

Normal Musculo-skeletal exam. Normal muscular development for age and sex. Normal strength. No deformation myalgia or arthralgia. Range of motion normal as tested. No localized tenderness. No localized edems. No clubbing of nails. No cyanosis of nails. Peripheral edema: none.

Skin

No rash. Skin not erythematous. Skin color pale. Skin warm. Skin dry. No clubbing of nails. No cyanosis of nails. Peripheral edema: none. No localized tenderness. No localized edema. No localized erythema.

Neuro/Psych

Normal neuro/psychiatric exam. Patient is awake, alert, cooperative and oriented to person place and time.

Anc. Tests

CBC

CBC normal range for current laboratory value.

CHEM 7

CHEM 7 normal range for current laboratory value.

Coagulation

Coagulation studies normal range for current laboratory value (for patient not taking anticoagulants).

Other labs

CK225. CKMB 8. Troponin I 1.6 ETOH Level 64.

X-ray

Chest X-ray impressions normal. Interpreted by emergency physician.

EKG

Heart rate 86. Rhythm normal sinus. ST segment changes (acute MI anterior). Normal intervals. No old EKG was available for comparison.

ED Course

Pain resolved. Observed in E.R. for: 1 hr 10 min(s). During this time:  Improved after treatment.  Conferred with Cardiology: E Bonner MD. Re-exam 1:  Re-examined at time: 10:38pam. Treatment NTG .6 SL. General appearance improved. Pain improved. Breathing stable. Neurologic status stable. Re-exam 2: Reexamined at time: 11:28 pm. General appearance stable. Pain improved.

Differential Diagnosis

Alcohol intoxication unlikely. Hypertension unlikely. Dehydration unlikely. Medication side effect unlikely. Thyroid disease unlikely. Chest wall strain unlikely. Chest wall fracture unlikely. Aortic tear unlikely. Asthma-acute exacerbation unlikely. Chest wall pain unlikely. Costochondritis unlikely. Viral pleuritis unlikely. Unstable angina unlikely. Pericarditis unlikely. Aortic dissection unlikely. Hyperventilation unlikely. Pulmonary embolus unlikely. Gastritis unlikely. Peptic ulcer disease unlikely. Psychiatric disorder unlikely. Anxiety disorder unlikely.

Diagnosis

Chest pain. Acute myocardial infarction (anterior).

Disposition

Condition of patient on leaving Emergency Department:  Stable. Critical. Admitted to ICU. Accepting physician: Green – ICU call. Medication: Morphine 8mg IV – NTG. Patient treated.

Reviewed and approved by: _______________________

Originator:  Paul Marchand, MD

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