Patient is a {AGE} year-old {SEX} presenting for {COMPLAINT}. Vitals {REMARKABLE/UNREMARKABLE} upon arrival. Initial physical examination {REMARKABLE/UNREMARKABLE). Patient has risk factors of {RISKS}. Obtained labs and imaging. Treated patient symptomatically.

Negative Chest Pain MDM

EKG not consistent with acute ischemic changes. Non-elevated troponins. CXR not consistent with acute cardiopulmonary findings. No clinically significant electrolyte abnormalities or anemia. Physical exam without evidence of volume overload. The above findings are not consistent with STEMI/NSTEMI, HF, PTX, Aortic Dissection, Pericarditis, or Tamponade. Presentation not consistent with acute PE given Wells Score or ***. Additionally, patient without infectious symptoms, which are not consistent with pneumonia or myocarditis. HEART Score {HEART SCORE}.

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If, patient has confirmed unstable angina or NSTEMI use TIMI

General: Well-appearing, no acute distress
Head: Normocephalic, atraumatic
Opthamalogic: No scleral icterus, no conjunctival erythema, PERRLA
ENT: Nares midline, no tracheal deviation
Cardiovascular: Normal rate, regular rhythm, no gallups/rubs/murmurs, no JVD, no lower extremity edema
Pulmonary: Non-labored, no adventitious breath sounds bilaterally
Abdominal: Soft, non-distentended, no rebound tenderness, no guarding
Genitourinary: No CVA tenderness bilaterally, GU exam deferred
Musculoskeletal: Moving all extremities equally, no obvious deformities
Neurological: Awake, alert, and oriented
Psychiatric: Appropriate affect and mood

, CN II-XII grossly intact
, capillary refill <3s
, thyroid non-tender

Visual Acuity:
- Non-pinhole:
- Pin-hole:
Pupilary Reflexes:
Intraoccular Pressure:
Gross Visual Fields:

Sclera:
Conjunctiva:
Lens:
Eye Lids:

OD: Right Eye, OS: Left Eye, OU: Both Eyes