ED Provider Notes at 07/15/21 0625 Procedure Orders 1. Electrical Cardioversion (ED) [409525162] ordered by Dr Post-procedure Diagnoses 1. Ventricular fibrillation seen on cardiac monitor (HCC) [I49.01]            Chief Complaint: Chest Pain     History:   62 y.o. male with hx of HTN and HLD who presents to the ED BIB wife with intermittent worsening central burning CP beginning a couple weeks ago now feels constant associated with dizziness today. CP is worsened with movement. He went to bed last night with CP, then woke up at 5:45Am with worsened pain. Last night he took pain medication, swallowed grape gum and then had CP. Denies SOB, N/V, hx of smoking or hx of DM. Denies FHX of early death due to MI. He has never had a heart attack before.       The history is provided by the patient. The history is limited by the condition of the patient.  Chest Pain The chest pain began 1 - 2 weeks ago. Duration of episode(s) is 1 week. Chest pain occurs constantly. The chest pain is worsening. The severity of the chest pain is severe. The quality of the pain is described as burning. Chest pain is worsened by certain positions. Primary symptoms include shortness of breath and dizziness. He describes the dizziness as a sensation of spinning. The dizziness began today. The dizziness has been unchanged since its onset.   His past medical history is significant for hyperlipidemia and hypertension.  Pertinent negatives for past medical history include no diabetes.  Pertinent negatives for family medical history include: no early MI.      Home Medications  Not on File     Allergies: Patient has no known allergies.   Past Medical History HTN and HLD. No hx of DM or MI.    Past Surgical History  Charts reviewed, the patient has no surgical history on file and none reported.    Social History No reported use of tobacco products, alcohol or illicit drugs.    Family History  No reported family history.  No early MI in family.    ROS: Review of Systems  Unable to perform ROS: Acuity of condition  Respiratory: Positive for shortness of breath.   Cardiovascular: Positive for chest pain (burning constant ). Neurological: Positive for dizziness.    Physical Exam: BP (!) 161/92  | Pulse 108  | Resp 27  | SpO2 100%  Pulse rate pulse OX: 96 bpm Physical Exam Procedures: Electrical Cardioversion (ED)     Sedation: Patient sedated: no   Cardioversion basis: emergent Pre-procedure rhythm: ventricular fibrillation Patient position: patient was placed in a supine position Chest area: chest area exposed Electrodes: pads Electrodes placed: anterior-lateral Number of attempts: 1 Attempt 1 mode: synchronous Attempt 1 waveform: biphasic Attempt 1 shock (in Joules): 150 Attempt 1 outcome: conversion to normal sinus rhythm Post-procedure rhythm: normal sinus rhythm Complications: no complications Patient tolerance: patient tolerated the procedure well with no immediate complications      EKG: EKG time (0626).   sinus tachycardia.   Rate: 101 bpm.   P waves Normal.   Normal PRI.  Normal QRS complex. Normal axis.   ST Segments: elevation in  v1, v2, v3 and v4 .  T Waves: non specific changes .    The study has been independently viewed by me.  The study has been interpreted contemporaneously by me.  The EKG appears to be a good tracing.    Clinical Impression: myocardial infarction  anterior        Rhythm Strip #1: Time (0638).   Lead II.  Rate= 200.   Rhythm: ventricular tachycardia.   Narrow QRS complexes.   Ectopy: none.   The study was interpreted by me.     EKG #2: EKG time (0646).   sinus tachycardia.   Rate: 110 bpm.   P waves Normal.   Normal PRI.  Normal QRS complex. Normal axis.   ST Segments: elevation in  v1, v2, v3, v4 and v5 .  T Waves: non specific changes .    The study has been independently viewed by me.  The study has been interpreted contemporaneously by me.  The EKG appears to be a good tracing.    Clinical Impression: myocardial infarction  anterior when compared to earlier ECG               Decision Support: ED Course:   62 y.o. male with hx of HTN and HLD presents with intermittent worsening central burning CP beginning a couple weeks ago now feels constant associated with dizziness today.    Initial exam notable for hear regular lungs clear and trace pitting edema. VS reviewed, hypertensive at 171/97, tachycardic at 116 and SPO2 is WNL.     DDx includes ACS including STEMI, tension pneumothorax, pulmonary embolism, ruptured esophagus, pneumonia, pericardial tamponade, traumatic hemothorax.     06:26 STEMI activated. Plan to obtain CBC, CMP, troponin and CXR.    06:30  I spoke with Dr. who accepts pt for transfer to cath lab. All transfer paperwork completed.    06:35 Pt suddenly went into V-fib then went into cardiac arrest, one round of compressions was done and he was shocked once into sinus rhythm. We gave magnesium, one ativan then pt's rate increased to 190, so then we shocked at 150 then pt went back to sinus rhythm, and started an amiodarone bolus 150.    --magnesium 2 g IV --amiodarone 1.5 mg/mL IV --heparin BOLUS 5,000 Units IV --heparin 1,000 Units infusion IV --amiodarone 150 mg IV --amiodarone 1 mg IV --Ativan 2 mg IV     Critical care time was provided for 35 minutes by the attending physician, exclusive of separately billable procedures and treating other patients.  This was necessary to treat or prevent further deterioration of the following condition(s) Circulatory failure which the patient had and/or had a high probability of suddenly developing.    Labs and Imaging Reviewed: CBC is WNL.  CMP shows elevated BUN at 24, elevated CR at 1.32 and hyperglycemia at 155. Troponin is elevated at 0.04. Covid PCR negative.  X-RAY of chest, a 1-view study, image reviewed by me, read by radiology, shows: No evidence of acute chest pathology.       Diagnosis and Disposition:   Impression: 1.   Chest pain, unspecified type  2.   Ventricular fibrillation seen on cardiac monitor (HCC)  3.   Cardiac arrest (HCC)    Condition: stable Disposition: Transfer to Hospital to Cath Lab       Scribing for and in the presence of, Dr.   Dr., personally performed the services described in this documentation, as scribed ED Notes Nurse at 07/15/21 0626 EKG  Nurse at 07/15/21 0627 EKG completed and given to dr. Patient brought directly back to room  ED Triage Notes Nurse at 07/15/21 0633 Patient presents to the emergency department with chest pain. Patient states he feels like his pain has been going on for a "couple weeks", worse this morning. States he has been taking tums and peptobsimal with no relief. Patient states the pain is sternal and burning in nature. States palpation made his pain worse. States he feels slightly short of breath "no more than normal." Patient skin is warm and dry.