CC: Sudden onset substernal chest pain that “woke me up “and lasted until now (about 45 mins)
HPI: 70 y/o man with h/o hypertension, hyperlipidemia, 40 pack-years smoking history, and brother who died of MI at 60y/o brought in by ambulance to the ED with c/o substernal chest pain. The pain is described as pressure-like and radiating to the left arm and jaw, accompanied by nausea, diaphoresis, and shortness of breath. Nitroglycerin was administered sublingually, but only provided temporary relief. Aspirin was given to the patient to chew in the ambulance.
PE:
VS: BP 150/70, HR 110, Temp 37.1 ͦC, R 30 Pulse oximetry: 96% on room air
Gen: obese, pale, diaphoretic patient
Lungs: clear to Auscultation and Percussion
Heart: RRR, S4 gallop noted
Ext: No cyanosis or edema
Labs:
CBC: Hemoglobin & hematocrit normal, WBC 11,000 (slightly high)
Electrolytes: Normal
Troponins: Troponin T and I are elevated
CK-MB: normal
EKG: sinus tachycardia, elevated ST segments in leads II, III, and AVF
Assessment: Acute Inferior wall MI
Plan: Start Morphine drip IV, O2 via nasal cannula, Metoprolol, urgent transfer to interventional cardiology lab
The patient has a balloon angioplasty and stent placement and is transferred to the telemetry unit for monitoring. You see the patient the next day and need to document your visit in a progress note in the SOAP format.
A very brief synopsis of what occurred the day previously
His current medications:
Aspirin 81 mg orally, once a day
Plavix 75 mg orally, once a day
Lopressor 25 mg orally every 12 hours
Patient report of his condition today: much more comfortable. No pain, no shortness of breath. Some mild fatigue when walking from room to nursing station
The EKG this morning shows normal sinus rhythm with no ST elevations and no Q-waves
The physical exam which includes HR 72, BP 130/70, R 24, Temp 37.4 ͦC
General: appears comfortable.
Extremities: peripheral pulses are slightly diminished and 1+
Heart: Regular rate and rhythm, no gallops or murmurs
Lungs: clear
Groin: femoral pulses intact and 2+ . No hematoma
Post-Procedure Note
S: 70yo male pt recovering post MI 1 day ago. Pt c/o substernal chest pain radiating to left arm and jaw with no improvement. In ED, pt had labs drawn and ekg done confirming inferior wall MI and was taken to cath lab where stent was placed through balloon angioplasty. Since, patient states he is much more comfortable and denies CHP or SOB. Shows slight fatigue on exertion.
O:
Interventions:
– Aspirin 81 mg orally, 1x daily
– Plavix 75 mg orally, 1x daily
– Lopressor 25mg orally q12
– HR 72, BP 130/70, R 24, Temp 37.4 C
General: appears comfortable.
Extremities: peripheral pulses are slightly diminished and 1+
Heart: Regular rate and rhythm, no gallops or murmurs
Lungs: clear
Groin: femoral pulses intact and 2+ . No hematoma
EKG: NSR with no ST-elevations
A: Inferior wall MI, S/P stent. Continuation of medications. On track for dc in a few days.
P: Have nurse continue current medication schedule while reassessing q4 vitals for one day then q8 thereafter. If pt remains stable with no further complications, pt can be dc home after 3 days.
