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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.