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

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.

Please write a SOAP note for your visit:

S: 70 y/o male treated yesterday for acute inferior wall MI, underwent balloon valvuloplasty and stent placement; patient currently reports no pain or SOB; mild fatigue on exertion

O: HR 72, BP 130/70, R 24, T 37.4 C

-gen – appears comfortable

-heart – no gallops/murmurs; EKG with NSR and absent ST elevation/Q waves

-extremities – slightly diminished peripheral pulses 1+

-lungs – clear

-groin – femoral pulses present 2+; no hematoma

A: patient is recovering well; no alarming signs

P: currently taking baby aspirin 1x daily, 75 mg Plavix 1x daily, 25 mg Lopressor 2x daily

-check vitals every 4 hours for the next 24 hrs; every 8 hrs thereafter

-if VS remain normal and no return of chest pain: discharge in 3 days