RECORD 01 | TYPE: EMERGENCY DEPARTMENT NOTE

PATIENT: Synthetic-001 | AGE: 58 | SEX: M | DATE: 2026-03-12 14:22
CHIEF COMPLAINT: Acute substernal chest pain radiating to the left jaw.

HISTORY OF PRESENT ILLNESS:
The patient is a 58-year-old male with a history of essential hypertension, hyperlipidemia, and a 30 pack-year tobacco history who presents via EMS with sudden-onset retrosternal pressure starting 75 minutes prior to arrival while mowing his lawn. He describes the pain as "like an elephant sitting on my chest," 8/10 intensity, radiating into his left shoulder and jaw. Associated with diaphoresis, mild nausea, and shortness of breath. Symptoms were partially relieved following 3 sublingual nitroglycerin tablets administered by EMS.

PAST MEDICAL HISTORY:
1. Hypertension x 12 years.
2. Hyperlipidemia.
3. Tobacco use disorder (active).

MEDICATIONS:
- Amlodipine 10 mg PO daily
- Atorvastatin 20 mg PO daily
- Aspirin 81 mg PO daily

PHYSICAL EXAMINATION:
Vitals: BP 158/92 mmHg, HR 98 bpm regular, RR 20 bpm, SpO2 96% on room air, Temp 36.8 C.
General: Diaphoretic, mildly anxious, clutching chest, speaks in full sentences.
Cardiovascular: Tachycardic, regular rhythm, S1/S2 present, no murmurs, rubs, or gallops. Normal peripheral pulses.
Pulmonary: Clear to auscultation bilaterally, no rales, wheezes, or rhonchi.
Abdomen: Soft, non-tender, non-distended.
Extremities: No lower extremity edema, calves soft and non-tender.

DIAGNOSTIC WORKUP:
- ECG (14:30): Normal sinus rhythm at 96 bpm. 2.5 mm ST elevations in leads II, III, and aVF with reciprocal ST depressions in I and aVL.
- Initial High-Sensitivity Troponin I: 342 ng/L (elevated).
- Portable Chest X-ray: No cardiomegaly, mediastinum within normal limits, no active pulmonary infiltrates or pneumothorax.

ASSESSMENT AND PLAN:
Acute inferior wall ST-elevation myocardial infarction (STEMI).
1. Emergent cardiac catheterization activation ("Code STEMI"). Interventional cardiology notified.
2. Aspirin 325 mg chewed given.
3. Ticagrelor 180 mg PO loading dose given.
4. Unfractionated heparin bolus 4000 units IV followed by infusion at 12 units/kg/hr.
5. Intravenous access x2 secured; continuous telemetry monitoring.
6. Transfer to Cardiac Catheterization Laboratory immediately.
