Original work only information of patient is on the 1 st document and 2 doc is the template needed due 10/15/2021 at 2 pm

Pt is a 60 yo female with PPH of AUD, schizophrenia, and DM experiencing CP. Pt reports that she had an MI on the 21st (though no record of this) and this feels the same. Pt describes the pain as crushing and tender in the center of her chest. She says he has shortness of breath, however able to speak in full sentences without difficulty. She rates it a 7/10 non radiating. Denies N/V, abdominal discomfort. Of note, pt has expressed similar complaints in the past with a negative workup. Pt adamantly refusing care beyond ibuprofen. She understands the ramifications of her condition, able to describe the consequences of not seeking care, and making a consistent decision throughout interview to not go to the ED.

DX Acute exacerbation of schizophrenia

Medications Abilify 15 mg daily and gabapentin 300 mg TID folic