Subjective:
Patient is a 70 y/o male with a PMHx of HTN. HLD, 40 pack year smoking history. Yesterday, he had a sudden onset of pressure like substernal chest pain that radiated to the left arm and jaw. It was associated with nausea, diaphoresis, shortness of breath. Treated with Nitroglycerin SUBQ with temporary relief. Labs were remarkable for elevated Troponin T and I. CK-MB within normal limits. EKG was remarkable for tachycardia and elevated ST segments in lead I, III and AvF indicating Acute Inferior wall MI. Treated with Morphine drip IV, O2 via nasal cannula and Metoprolol. Transferred to interventional cardiology lab where a balloon angioplasty and stent placement was done. Status post procedure, patient was transferred to the telemetry unit for monitoring.
Objective:
Patient is currently being treated with Aspirin 81 mg PO QD, Plavix 75 mg PO QD and Lopressor 25 mg PO BID.
Denies pain, SOB. Reports mild fatigue
EKG: Normal Sinus Rhythm (-) ST elevation, (-) Q waves.
Physical exam:
R 72, BP 130/70, R 24, Temp 37.4 ͦC
General: appears comfortable.
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:
Patient is a 70 year old male, status post balloon angioplasty and stent placement secondary to Acute Inferior wall MI. EKG is changed and shows no ST elevation or tachycardia. No sign of infection. Physical exam is within normal limits and lab work shows no evidence of MI.
Continue to monitor the patient to ensure the patient does not become infectious secondary to stent placement and balloon angioplasty.
Plan:
Patient responded well to treatment, balloon angioplasty and stent placement.
Continue the current medications.
