Number and Complexity of Problems
Differential Diagnosis: ACS, pneumonia, pneumothorax, cardiac tamponade, aortic dissection, myocarditis
Comorbidities: See HPI

MDM Data
Reviewed external records: [-]
Summary of lab findings: [-]
My EKG interpretation: [-]
My independent CT interpretation: [defer to radiologist interpretation for official result]
My independent X-ray interpretation: [defer to radiologist interpretation for official result]
My independent Ultrasound interpretation: [defer to radiologist interpretation for official result]
Decision rules/scores evaluated: N/A

ED Course: [one-liner] Exam without evidence of volume overload so doubt heart failure. EKG without signs of active ischemia. Given the timing of pain to ER presentation, single troponin▼ was negative so doubt NSTEMI. Presentation not consistent with acute PE (PERC▼ negative), pneumothorax (not visualized on CXR), thoracic aortic dissection, pericarditis, tamponade, pneumonia (no infectious symptoms, clear CXR), myocarditis (no recent illness, neg trop). HEART score is [] so plan to admit patient for risk stratification▼.

Treatment and Disposition
Social determinants of health that impact treatment/disposition: .
Shared decision making: I have discussed with the patient around diagnostics, treatment, and disposition decisions▼
Code status: Presumed Full Code▼