S: 70 y/o patient came into the ER yesterday complaining of an acute onset of substernal chest pain and was found to have an acute inferior wall MI. The patient was started on Morphine, Metoprolol, Aspirin, Plavix and Lopressor. Patient had a balloon angioplasty and stent placed. Today, the patient is more comfortable, has no chest pain or shortness of breath. The patient is experiencing some mild fatigue when walking from the room to the nursing station.

O: Patient is much more comfortable. No pain, no shortness of breath. Some mild fatigue when walking from room to nursing station

The EKG this morning shows normal sinus rhythm with no ST elevations and no Q waves
The physical exam which includes: HR 72, BP 130/70, R 24, Temp 37.4 Cͦ General: appears comfortable. Extremities: peripheral pulses are slightly diminished and 1+
Heart: Regular rate and rhythm, no gallops or murmurs
Lungs: clear
Groin: femoral and pedal pulses intact and 2+ . No hematoma

A: Follow up on Acute Inferior wall MI and surgery. Mild fatigue from walking is normal as the patient recently had a balloon angioplasty done.

P: Keep patient on Aspirin, Plavix and Lopressor medication. Nurse to check his vitals every 4 hours for one more day and then every 8 for 2 days. If the patient’s condition continues to improve, the patient can be discharged in 3 days from today.