(This document doesn’t reflect the views or opinions of the Department of Defense, the US Army, or the SAUSHEC EM residency, © 2012 EM Basic, Steve Carroll DO. May freely distribute with proper attribution)
Chief complaint
History of present illness with pertinent positive and negatives
Brief review of systems
Focused Past medical and surgical history
Focused pertinent medications and allergies
Very focused social history and family history if required
Vitals- highlight any abnormal vital signs
Focused and pertinent physical exam
Differential diagnosis- 3 life threatening things followed by what you think it is
Plan- what you want to do
Disposition- Patient being discharged, needs more testing before a decision, or is being admitted no matter what the testing shows.
Chief complaint- I have a 50 year old male with chest pain
History of present illness with pertinent positive and negatives
The pain started at rest 3 hours ago while he was watching TV. He describes it as a pressure like sensation in his chest with no radiation. The pain came on gradually over 30 minutes and peaked at an 8 out of 10 intensity. Nothing made it better or worse, and the pain went away on his way into the ED
Brief review of systems- He denies shortness of breath, diaphoresis, nausea, vomiting, abdominal pain, or recent illnesses. He has no DVT or PE risk factors.
Focused Past medical and surgical history- The patient has hypertension and his only surgeries are a remote apply and knee surgery
Focused pertinent medications and allergies- His only medication is lisinopril and he has no allergies
Very focused social history and family history if required- Father had an MI at 60 years old, and he doesn’t smoke, drinks occasionally, and denies illicit drug use, specifically denies cocaine use.
Vitals- Significant only for a BP of 150/90
Focused and pertinent physical exam- On exam, his lungs are clear and his heart has no murmurs, rubs, or gallops. I cannot reproduce his chest pain with palpation. He has no peripheral edema and the rest of his exam is normal.
Differential diagnosis- My differential includes MI or ACS, PE, and aortic dissection. I don’t think he has a PE or aortic dissection given no PE risk factors and his history isn’t consistent with dissection.
Plan- He got an EKG in triage that shows normal sinus at a rate of 80 with normal axis and intervals, and no ST/T wave changes. For further workup, I would like to get a portable chest x-ray, a cardiac lab set with CBC, chem 10, coags, troponin and CK, CK-MB. I would also give him 325 mg of aspirin.
Disposition- If his labs and chest x-ray are negative and he continues to be pain free, I would admit him for a low risk rule out.
EM-Basics has a great resource on student presentation. Link below:
http://embasic.org/how-to-give-a-good-ed-patient-presentation/