OneSim

James Morrow

MRN-00142Room 412A
DOB: 1961-03-14 (64M)Attending: Dr. A. ChenAdmitted: TodayDx: Chest pain — R/O NSTEMI
ALLERGY: Sulfa drugs (rash)
BP
138/82
HR
78 bpm
SpO2
99%
Temp
36.9°C

Chief Complaint

Chest pain × 2 days, substernal, radiating to left jaw. Rated 7/10 at onset; currently 3/10.

HPI Summary

64 yo male with HTN and hyperlipidemia. Chest pressure began at rest. Denies SOB, diaphoresis, palpitations. Antacids provided no relief. Former smoker (10 pk-yr).

Past Medical History

  • Hypertension (HTN)
  • Hyperlipidemia
  • Former tobacco use

Social History

Former smoker — approximately 10 pack-year history. Quit 8 years ago. Occasional alcohol use. Lives with spouse.

Current Vitals (Latest)

BP
138/82
HR
78 bpm
RR
14 breaths/min
Temp
36.9°C
SpO2
99%

Active Medications

  • Aspirin 325mg POScheduled
  • Metoprolol tartrate 25mg POScheduled
  • Heparin (unfractionated) 1000u/hr IVRunning
  • Nitroglycerin SL 0.4mg SLPRN

Allergies

Sulfa drugs — Rash

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