CASE:
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.
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
His 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 and pedal pulses intact and 2+ . No hematoma
You believe he is doing well and that the same plan should be continued for now. You would like the nurse to check his vital signs every 4 hours for one more day and then every 8 hours.
If all goes well, he can be discharged in 3 days.
SOAP NOTE:
S:
70 y/o male with history of hypertension, hyperlipidemia, 40 pack-years smoking history and positive family history of MI brought into ED yesterday complaining of 45 minutes of substernal chest pain described as pressure like that radiated to left arm and jaw accompanied by nausea, diaphoresis, and shortness of breath. Nitroglycerin was administered sublingually and provided temporary relief. Aspirin was administered in ambulance. Patient was diagnosed with acute inferior wall MI and started on morphine drip IV, O2 via nasal cannula, Metoprolol and was urgently transferred to interventional cardiology lab where he had a balloon angioplasty and stent placement. Patient was then started on Aspirin 81 mg orally once a day, Plavix 75 mg orally once a day, and Lopressor 25 mg orally every 12 hours. Transferred to telemetry unit for monitoring. Patient reports being much more comfortable today, with no pain or shortness of breath, but some mild fatigue upon exertion.
O:
Vital signs: HR 72, BP 130/70, R 24, Temp 37.4 ͦC
Physical Exam:
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
EKG: normal sinus rhythm with no ST elevations and no Q waves
A:
Post PCI fatigue accompanied by slightly diminished pulses. Patient otherwise recovering well with normal vital signs.
R/O blot clot (unlikely, but possible after stent procedure)
R/O peripheral vascular disease (unlikely, but possible due to slightly diminished pulses)
P:
Patient should continue with medications as below:
- Aspirin 81 mg orally, once a day
- Plavix 75 mg orally, once a day
- Lopressor 25 mg orally every 12 hours
Nurse should check vital signs every 4 hours x 1 day then every 8 hours
If no complications, patient may be discharged in 3 days.
