Cerner/Dictation Pearls

“My low risk chest pain MDM” – Rob

This is a [36-year-old female] comes in for evaluation of [her] acute intermittent chest pain symptoms. Multiple emergent diagnoses were considered for this patient, however based on the current evaluation there is no evidence of acute coronary syndrome, and per the HEART score, their risk of a major cardiac event is less than 2% in the next 6 weeks. The patient agrees they can safely be discharged with further outpatient cardiac risk stratification if necessary through their primary care doctor. I also considered pulmonary embolism, however the patient has normal vital signs, and per the PERC criteria, I do not feel that any CTA chest or d-dimer is warranted at this time. Clinically, I doubt the patient has aortic dissection, there is no x-ray evidence of pneumonia, pneumothorax, or pneumomediastinum. The etiology of the pain at this time is unclear however the patient is agreeable to followup with a primary care doctor in the next 2-3 days for further evaluation. The patient understands and agrees with the plan, has no further questions, and was given strict return precautions. Extensive oral and written discharge instructions were provided.