[##-year-old male/female] with chest pain with history and exam
consistent with likely [presumptive diagnosis/chest wall pain].
Initial consideration in this patient included angina pectoris, acute coronary syndromes (ACS) including stable and unstable angina, dysrhythmias, pulmonary embolism (PE), aortic dissection, pneumothorax, pneumonia, esophageal etiologies, chest wall pain including costochondritis, and pleuritis among others.
Patient presented with complaint of chest pain described as
[constant/intermittent sharp/pressure] for the past [duration]. A 12-lead EKG was obtained with [describe findings without evidence of acute ischemia or infarction/no evidence
of dysrhythmia, ischemia, infarction, or other significant abnormalities]. The patient was felt to be low risk for PE
based on a low risk Well’s score and being PERC negative. We obtained a troponin in the evaluation of
this patient, which was noted to be [undetectable/below the normal
limit/etc. at presentation and on repeat assessment at 3 hour interval]. The patient was noted to
have a HEART score of [##] as noted above.
Plain films of the chest were obtained with no evidence suggestive of
dissection, pneumonia, pneumothorax, or other significant pathology. Considered esophageal etiology
[unlikely/likely] based on [absence of] relation to eating, and [no]
significant improvement with GI cocktail in the ED.
Patient reported improvement with [treatment] prior to discharge from
ED. We discussed appropriate follow up
based on a HEART score of [##/0-3] with the patient as noted above. After discussion of all of the risks and
benefits of the available options with the patient demonstrating understanding,
they wished to [be admitted to observation for further testing/follow up with
their primary care provider within the next week for further evaluation/have a
follow up appointment arranged in the next ## for further evaluation prior to
discharge].
Prior to discharge, we discussed return precautions, specifically for
evidence of persistent or worsening chest pain, treatment [with
analgesics/antacids/NSAIDs], and follow up plan, and the patient demonstrated
understanding and agreement.
https://rebelem.com/management-and-disposition-of-low-risk-chest-pain/
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