S:

XX is a 70 y/o man with hypertension, hyperlipidemia, obesity, 40 pack-years smoking history and a brother who died of MI at 60 y/o

Presented to ER c/o retrosternal chest pain described as “pressure” and radiating to left arm/jaw.

Dx acute inferior wall MI yesterday (specific date would go here) with subsequent balloon angioplasty and stent placement. 

O:

Vitals: BP 130/70, HR 72, R 24, Temp 37.4 C

EKG: normal sinus rhythm, no ST elevations, no Q waves

General: appears comfortable

Extremities: slightly diminished peripheral pulses and 1+

Heart: regular rate and rhythm, no gallops or murmurs

Lungs: clear

Groin: femoral pulses intact and 2+, no hematoma

A:

Recovering from acute inferior wall MI previous day w/ subsequent stent

Vitals are stable, EKG normal, and no report of pain or SOB. 

Mild fatigue noted walking from bed to nurses’ station.

P:

Continue:

Aspirin 81 mg orally, once a day

Plavix 75 mg orally, once a day

Lopressor 25 mg orally every 12 hours

Check vitals every 4 hrs for one more day, followed by every 8 hrs

If VS stable and denies chest pain Pt may be discharged home in 3 days