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Rm 22

87M — Chest pain

HPIPhysical ExamMDM

Emergency Department Note

87yo M w/ HTN, HLD, DM2 p/w substernal chest pressure x2h at rest, 7/10, non-radiating, assoc dyspnea. Denies diaphoresis, nausea. No prior similar episodes. Meds: lisinopril 20mg, atorvastatin 40mg, metformin 1000mg BID.

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Mr. Johnson is an 87-year-old male who presents to the emergency department with a chief complaint of chest pain. The patient reports substernal chest pressure that began approximately 2 hours prior to arrival while resting at home.

The pain is described as a pressure-like sensation, rated 7/10 in intensity, non-radiating, and associated with mild dyspnea. He denies diaphoresis, nausea, vomiting, or palpitations. He has not experienced similar symptoms previously.

Past medical history is significant for hypertension, hyperlipidemia, and type 2 diabetes mellitus. Current medications include lisinopril 20mg daily, atorvastatin 40mg nightly, and metformin 1000mg twice daily.

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Emergency Department Note

Gen: A&Ox3, mild distress. CV: RRR, no m/r/g. Pulses intact bilat. Resp: CTA bilat. No wheezes/rales. Abd: soft NTND, BS+. Ext: No LE edema. Calves NT bilat.

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Constitutional: Alert, well-appearing male in mild distress. No acute toxic appearance.
HEENT: Normocephalic, atraumatic. Mucous membranes moist. No JVD.
Cardiovascular: Regular rate and rhythm. No murmurs, rubs, or gallops. Peripheral pulses intact bilaterally.
Respiratory: Clear to auscultation bilaterally. No wheezes, rales, or rhonchi. No respiratory distress.
Abdomen: Soft, non-tender, non-distended. Bowel sounds present.
Extremities: No lower extremity edema. Calves non-tender bilaterally.
Neuro: Alert and oriented x3. No focal neurologic deficits.
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Emergency Department Note

87yo M w/ HTN, HLD, DM2 p/w substernal chest pressure x2h. Onset at rest, 7/10, non-radiating. Assoc mild dyspnea. Trop-I 0.12 [H], BNP 180, ECG: NSR w/ 1mm ST dep V4-V6. CXR: mild cardiomegaly.

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This 87-year-old male presents with acute onset substernal chest pressure, concerning for acute coronary syndrome. The differential diagnosis includes STEMI/NSTEMI, unstable angina, aortic dissection, pulmonary embolism, and musculoskeletal etiologies.

He is hypertensive at 158/94 with otherwise stable vitals. His ECG demonstrates sinus rhythm with ST depressions in V4–V6, and troponin-I is elevated at 0.12, consistent with myocardial injury; chest X-ray without acute cardiopulmonary process, and comprehensive metabolic panel within normal limits. Given the patient's age and risk factor profile, serial troponins and repeat ECG were ordered.

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EMRHyperspace – BHMC EMERGENCY
📄🔍New OrderPrintRefresh
JOHNSON, ROBERT A
MRN: 4728293DOB: 06/12/1938 (87y)M⚠ Allergy: PCN
ED Rm 22 • ESI-2
Attending: Dr. Chen
SummaryChart ReviewNotesOrdersResultsMAR
ED Provider Note — 03/15/2026 14:32

Chief Complaint: Chest Pressure

HPI

87yo M w/ PMHx HTN, HLD, DM2 presenting w/ substernal chest pressure x2h. Onset at rest, 7/10 severity, non-radiating. Associated mild dyspnea. Denies N/V, diaphoresis, syncope. No prior cardiac hx. Takes lisinopril, metformin, atorvastatin.

Vitals
TempHRRRBPSpO2
36.89618158/94 ⚠97% RA
Results
TestValueRef RangeFlag
Trop-I0.12<0.04H ▲
BNP180<100H
Cr1.10.7-1.3Normal
ECG

NSR at 96 bpm. Normal axis. 1mm ST depression V4-V6. No reciprocal changes. QTc 440ms.

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Encounter

HPIEXAMMDM

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62F — Dyspnea

HPIMDM

1 hr ago

Encounter

HPIPhysical ExamMDM
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encountER

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87M — Chest pain

MDM

In progress

62F — Dyspnea

HPIMDM

1 hr ago

87M — Chest pain

HPIPhysical ExamMDM

Emergency Department Note

87yo M w/ HTN, HLD, DM2 p/w substernal chest pressure x2h. Onset at rest, 7/10, non-radiating. Assoc mild dyspnea. Trop-I 0.12 [H], BNP 180. ECG: NSR 96bpm, 1mm ST dep V4-V6. CXR: mild cardiomegaly.

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Yes. encountER is fully HIPAA compliant. All data is encrypted with 256-bit AES encryption both in transit and at rest. Our infrastructure runs in U.S.-based data centers with SOC 2 Type II certification. We sign BAAs with all customers.

encountER works alongside any EHR. It runs in your browser — provide a brief summary or simply copy and paste the generated documentation into Epic, Cerner, Meditech, or whichever system you use. We are developing direct integrations and will announce them soon.

Nabla and other AI note assistants are mostly speech-to-text tools — they transcribe what you say with sparse clinical reasoning. encountER is a robust AI documentation assistant that understands clinical reasoning. Give it a brief summary or drop your entire note with labs/imaging included and it generates a structured, billing-appropriate HPI, Physical Exam, and MDM. It doesn’t just write what you say; it thinks through the documentation like a seasoned EM physician.

encountER is $119/month for unlimited access to all tools — MDM Assistant, HPI Assistant, Clinical Decision Support, Knowledge Base, Chart Analysis, E/M Level Capture, and more. At 120–140 clinical hours per month, that’s less than $1 per clinical hour. We offer a 30-day free trial with no credit card required, and group discounts for practices.

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