This is a progress note for a patient who suffered from an Acute Inferior wall MI
S: Pt is comfortable and denies CP. No S.O.B, but pt. reports mild fatigue when walking from room to nursing station.
Pt is taking Aspirin 81 mg orally, once a day, Plavix 75 mg orally, once a day and Lopressor 25 mg orally every 12 hours
O: VS: HR 72, BP 130/70, R 24, Temp 37.4 ͦC
General: appears comfortable, no acute distress
CV: Regular rate and rhythm
RESP: Lungs are clear, no gallops or murmurs
PVR: Peripheral pulses are slightly diminished and 1+, femoral pulses intact and 2+, no hematoma.
EKG (morning)- Normal sinus rhythm, no ST elevations, no Q waves.
A: Pt is 70 y/o man post -acute Inferior wall MI from yesterday. Pt has h/o hypertension, hyperlipidemia, 40 pack-years smoking history and fhx of a brother who died of MI at 60y/o. Pt appears to be in good condition for now.
P: Continue patient on current medications and check pt. vital signs every 4 hours for one more day and then every 8 hours. Discharge patient in 3 days if pt. is w/o CP and VS are stable.
Disclaimer: This is a fictional character for an assignment.