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.