The patient is here with complaints of left-sided chest pressure.  Patient does have a history of cardiac stents placed in 2017.  He is not on any blood thinners at this time.  He stated that it woke him up out of his sleep around 4:00 and did get worse with activity at work.  He denies any nausea or vomiting or cold sweats.  Denies any recent fevers.  Does stated that he does have a little bit of nasal drainage but denies any other cough or cold-like symptoms.  Denies any shortness of breath.  Review of Systems     Constitutional: No fevers, chills, sweats, weakness, or fatigue  Eye: No recent visual problems  ENT: No ear pain, no ear drainage, nasal congestion, or sore throat, small amt of nasal drainage  Respiratory: No shortness of breath, no cough, no wheezing  Cardiovascular: Left-sided chest pressure, no palpitations, no syncope  Gastrointestinal: No nausea, vomiting, diarrhea, abdominal pain, or abdominal distention  Musculoskeletal: No back pain, neck pain, joint pain, or muscle pain  Integumentary: No rash, pruritus, or abrasions  Neurologic: Alert & oriented X 4, no headache, no dizziness, no numbness or tingling  Physical Exam       General: Alert and oriented, well nourished, no acute distress.  Lungs: Clear to auscultation all lung fields, non-labored respiration.  Heart: Normal rate, regular rhythm, no murmur, gallop or edema.  Abdomen: Soft, non-tender, non-distended, normal bowel sounds, no masses.  Musculoskeletal: Normal range of motion and strength, no tenderness or swelling, no deformities or step offs.  Skin: Skin is warm, dry and pink, no rashes or lesions.  Neurologic: Awake, alert and oriented X4.  Psychiatric: Cooperative, appropriate mood and affect.   Heart score: 4  Assessment/Plan      1. NSTEMI (non-ST elevated myocardial infarction) I21.4   The patient is not ill-appearing or toxic upon arrival to the emergency room.  He stated since laying in the bed he did start having improvement of his chest pain but when he was working and pulling about 25 to 50 pounds worth of steel his chest pain was escalating.  He denies taking anything for it.  Does have a history of a stent that was placed in 2017.  His heart score today is 4 this is a moderate score.  His repeat troponin did increase by 11 points.  This is concerning for acute injury to the heart and will need to be closely monitored over the next 48 hours.  We did contact HCF Dr.  who did want the patient to be transferred to their stepdown unit for further investigation of his increasing troponin and most likely need a possible heart cath at that time.  He recommend placing him on heparin right away.  Unfortunately since the patient did test positive for COVID, they were unable to take him due to lack of beds.  I did discuss his case with his cardiologist,  recommended putting him in the hospital for at least 48 hours and then sending him home on Plavix and have him follow-up with her for an echo and stress test and most likely a catheterization at that point.  Since he tested positive for COVID, he is not a candidate for stent placed seen at this time.  We will be placing him on heparin and rechecking his PTT every 6 hours and titrating the heparin per the protocol.  He is on the other appropriate medications that include a statin and metoprolol.  We did not need to make any changes with that at this time.  The patient's chest pain went away completely.  His 3-hour troponin did come back elevated again at 44.  We will recheck his troponin tomorrow morning unless he starts having chest pain again  To make sure that it is trending down.  He had no EKG changes.  He was given 4 baby aspirin in the emergency room.  I discussed the patient with his PCP,,  who was agreeable with this plan of c family is also agreeable, they deny any further concerns at this time.  I do not suspect a are.  DVT or PE that could be causing right sided heart strain, due to negative CT scan.   2. COVID-19   The patient is basically asymptomatic at this time.  I do not believe that steroids or remdesivir are needed.  I do not suspect pneumonia.  We will continue to monitor this.   Orders:   heparin additive 25,000 unit(s) + premix diluent 250 mL, 250, mL, IV, Routine, Start date 01/10/22 12:23:00 CST, titrate see comments, Total volume (mL): 250, 95.25 kg, 2.08, m2, 01/10/22 12:23:00 CST  Consult to Pharmacy, Pharmacy Consult, Misc, N/A, On Call, Routine, Start date 01/10/22 12:23:00 CST, 01/10/22 12:23:00 CST  Cardiac Monitoring, 01/10/22 9:25:00 CST, Constant Order  Complete Blood Count with Automated Differential, Blood, Routine collect, 01/10/22 12:23:00 CST, Stop date 01/10/22 12:23:00 CST, dc order if already done  CT Angio Chest PE w/ Cont, 01/10/22 10:57:00 CST, Routine, 01/10/22 10:57:00 CST, chest pain, elevated troponin, No, Transport Mode: Walk, , No, , No, Rad Type  Patient Transfer Order, 01/10/22 9:20:00 CST  PT/INR, Blood, Routine collect, 01/10/22 12:23:00 CST, Stop date 01/10/22 12:23:00 CST, dc order if already done  PTT, Blood, Routine collect, 01/10/22 12:23:00 CST, q6hr (interval), Lab Collect  Pulse Oximetry Check - Nursing, 01/10/22 12:23:00 CST, q4hr (scheduled), to be monitored continuously  Telemetry, 01/10/22 12:23:00 CST, q4hr (scheduled)      acute profee: medium  The patient is to be admitted for at least 48 hours to be placed on a heparin drip and to trend his troponins.  The patient is at high risk for worsening cardiac injury.  He will be placed on telemetry and we will monitor his chest pain closely.  If he has recurrence of his chest pain or his troponin keeps continuing to go up or having changes on his EKG, he will need to be transferred to higher level of care.  If discharged to go home or released too early he is at high risk for worsening cardiac injury, arrhythmia, heart failure, death   DDx: MI, GERD, chest wall  pain, PE, pleurisy, arrhythmia, nerve pain, esophageal spasm, all of the differentials considered and not limited to this list.