Soap Note:
Nicole Arrington
Subjective:
“pain woke me up”
Patient admitted to hospital on November 2, with sudden onset substernal chest pain, pressure-like and radiating to the left arm and jaw, accompanied by nausea, diaphoresis, and shortness of breath, Heart: Heart: RRR, S4 gallop noted
Elevated troponin T and I, sinus tachycardia, elevated ST segments, a balloon angioplasty and stent placement on November 2. Hemoglobin & hematocrit normal, WBC 11,000.
Today, Pt. reports no pain, no shortness of breath. Some mild fatigue when walking from room to nursing station
General: appears comfortable.
Objective:
EKG -normal sinus rhythm with no ST elevations and no Qwaves
HR 72, BP 130/70, R 24, Temp 37.4 ͦC
Extremities: peripheral pulses are slightly diminished and 1+
Heart: Regular rate and rhythm, no gallops or murmurs
Lungs: clear
Groin: femoral pulses intact and 2+ . No hematoma
Assessment:
Main Problem
- 70 year old male admitted and diagnosed with Acute Inferior wall MI
after patient presented with pressure-like pain and radiating to the left arm and jaw, accompanied by nausea, diaphoresis, and shortness of breath, sinus tachycardia, elevated ST segments in leads II, III, and AVF, elevated Troponin T and I, Heart: RRR, S4 Gallop.
- balloon angioplasty and stent placement November 2
- appears comfortable, reports no pain and no S.O.B
- Extremities: peripheral pulses are slightly diminished and 1+
- Heart: Regular rate and rhythm, no gallops or murmurs
- Lungs: clear
- Groin: femoral pulses intact and 2+ . No hematoma.
Plan:
Continue monitoring pt.
- nurse to check his vital signs every 4 hours for one more day and then every 8 hours.
- Continue current medication:
Aspirin 81 mg orally, once a day
Plavix 75 mg orally, once a day
Lopressor 25 mg orally every 12 hours
- If patient is without chest pain and VS are stable, he can be discharged to home in 3 days.