A very brief synopsis of what occurred the day previously

His current medications:

Aspirin 81 mg orally, once a day

Plavix 75 mg orally, once a day

Lopressor 25 mg orally every 12 hours

His report of his condition today:  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 Qwaves

The physical exam which includes: HR 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

You believe he is doing well and that the same plan should be continued for now.  You would like the nurse to check his vital signs every 4 hours for one more day and then every 8 hours. 

If all goes well, patient is without chest pain and VS are stable, he can be discharged to home in 3 days.

Please write a SOAP note for your visit:

S: 70 y/o male was admitted to the ER yesterday due to Acute Inferior wall MI and was treated with Morphine drip IV, O2 via nasal cannula, Metoprolol, and interventional cardiology lab. Currently, he is feeling well and denies shortness of breath. Admits to some fatigue while walking. Currently taking Aspirin 81 mg qd, Plavix 75 mg qd, and Lopressor 25 mg bid. EKG showed no ST elevations or Q waves.

O: HR 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

A: Patient with previous acute inferior wall MI, currently stable

P: Continue current medication regimen

Vital signs should be monitored every four hours for more than one day, then every 8 hours

Patient can be discharged in 3 days if symptoms do not worsen