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
The next day you visit the patient and must write a progress note to include the following:
A very brief synopsis of what occurred the day previously (including the treatment given in interventional cardiology)
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 reports 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 and pedal pulses intact and 2+ . No hematoma
Post-Procedure Note
S: 70 y/o M admitted to the ED yesterday because pt was c/o chest pain that was radiating to left arm and jaw. During the ED visit, labs were drawn, EKG was performed, which confirmed pt was having an Acute Inferior wall MI. Pt was transferred to cardiology lab and had a balloon angioplasty, and a stent was placed.
O:
HR 72, BP 130/70, R 24, Temp 37.4 ͦC
Medication:
– Aspirin 81 mg orally, 1x daily
– Plavix 75 mg orally, 1x daily
– Lopressor 25mg orally q12
Extremities: peripheral pulses are slightly diminished and 1+ edema
Heart: Regular rate and rhythm, no gallops or murmurs
Lungs: clear
Groin: femoral pulses intact and 2+. No hematoma
A: Pt s/p stent placement after having an acute inferior wall MI. Pt is currently stable with current medication regiment, and stable for d/c.
P: Continue current medication regiment.
Monitor patient for the next 3 days with the nurse checking vital signs every 4 hours for the first day, and then 8 hours. If patient is stable at day 3 then d/c.
Follow-up with cardiology in 2 weeks.
