Hahn, Frank D.O.B. 1/27/1948
(ID # 3425602440)
South Health System ED: Tues., Feb 21, 2007 5:15 PM

Chief Complaints
Presented to ED via city medics with chest pain.

History of Present Illness
Shortness of breath, nausea, vomiting. Pain characterized as pressure on chest with radiation to the left arm. Duration more than 20 min.

ROS
Vital Signs:
Temp 99 F
pulse 125/min
BP 170/95
RR 14
C/V: Regular rhythm, no murmurs
RESP: CTA

Physical Examination
Cold clammy skin, Febrile,
RR 14, BP 170/95

Diagnosis:
Myocardial Infarction

ECG:
ST elevation > 2mm
in leads V2-V4

General Labs:
CPK-MB: Awaiting results
Total CPK: Awaiting results
Troponin: Awaiting results
Hgb: 15.5 g/dL
WBC 6.0 x 10,000 per μL
Hct: 40%
Plates 350 x 10,000 per μL
Bun/Crea: 7 mg/dL/ 0.6 mg/dL
Ca: 8.4mg/dL
Mg 1.3 mEq/L
Phos 2.7 mg/dL
Coag profile: PT-11 secs