Case 1
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: Pt. 70 y/o male with medical h/o hypertension, hyperlipidemia, 40 pack year smoking history, and positive family h/o MI brought in to ED yesterday c/o substernal chest for 45 mins that radiated to left arm and jaw accompanied with nausea, shortness of breath, and diaphoresis. Pt. was diagnosed with STEMI after labs showing elevated WBC Troponin I and T along with an EKG with elevated ST segments in leads II, III, and AVF, balloon angioplasty and stent were placed. Pt. was also started on Aspirin 81 mg orally, once a day, Plavix 75 mg orally, once a day, Lopressor 25 mg orally every 12 hours. Today, pt. denies shortness of breath and chest pain but c/o fatigue when walking to and from nurse’s station.
O:
Vitals: 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
Labs: Morning EKG shows normal sinus rhythm with no ST elevations and no Q waves
A:
Diagnosis: 70 y/o male with h/o of hypertension, hyperlipidemia, and 40 pack smoking history was admitted to ED yesterday after treatment of acute inferior wall MI treatment with balloon angioplasty and stent placement healing well with post-procedural fatigue with excessive movement.
Differential Diagnosis:
- Obesity induced fatigue: depending on severity of obesity
- PAD: diminished peripheral pulses and fatigue, h/o smoking, obesity
- Atherosclerosis: recent MI, diminished peripheral pulse, h/o hyperlipidemia
P:
- Continue Aspirin, Plavix, and Lopressor as previously prescribed
- Check vitals every 4 hours for one more day then every 8 hours
- If vitals are stable and pt. is stable without any symptoms rule out PAD and Atherosclerosis, pt. can be discharged after 3 days
- F/u with Cardiology in 2 -3 weeks
- Recommendation for smoking cessation
- Obesity counseling
