** All names & scenarios are fictional for the purpose of learning education. **

HPI: 70 y/o man with h/o hypertension, hyperlipidemia, 40 pack-years smoking history, and brother who died of MI at 60y/o brought in by ambulance to the ED with c/o substernal chest pain.  The pain is described as pressure-like and radiating to the left arm and jaw, accompanied by nausea, diaphoresis, and shortness of breath.  Nitroglycerin was administered sublingually, but only provided temporary relief.  Aspirin was given to the patient to chew in the ambulance. Patient was immediately brought to the cardiology lab and had a balloon angioplasty and stent placement and was transferred to the telemetry unit for monitoring.

S : 70 yo man completed a balloon angioplasty and stent placement yesterday (11/9/2020) due to acute inferior wall MI. 

• Denies pain & shortness of breath
• Reports mild fatigue when walking from room to nursing station
• States present condition is comfortable
• States no adverse effects to sublingual nitroglycerine, aspirin, Morphine drip IV, O2 nasal cannula, & Metoprolol that administered prior to stent placement

O :

HR: 72 bpm

BP: 130/70

R: 24

Temp: 37.4   ͦC

EKG: normal sinus rhythm with no ST elevations and no Q waves

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.

A :  Patient is stable with vitals signs within normal range. R/O bleeding. R/O blood clots. R/O heart complications.

P : Continue monitoring the patient for the next 3 days. A nurse will monitor vital signs every 4 hours for the first day and then every eight hours.

Patient is currently taking:

• Aspirin 81 mg orally, once a day
• Plavix 75 mg orally, once a day
• Lopressor 25 mg orally every 12 hours

If stable for 3 days, patient may be discharged. Discuss medication plan for patient to continue after discharge. Follow-up with the patient in 2 weeks or sooner if symptoms of dyspnea, nausea, vomiting, or heart palpitation appear.