Progress Note-D3
Medicine Gold
R2 Phillips
MS4 digitalis
49 y/o m w/ PMH of CAD, CVA, HTN, DM s/p CABG on D3 of admission for central chest pain with ST elevation and +ve troponin
S:
Nursing staff report pt feeling SOB overnight. Gave nitro and paged on call intern for workup. Night float reported pt. SOB with crackles bibasally w/ evidence of pitting edema-gave lasix and nitro drip.
Pt. feeling more comfortable this morning. No CP. No SOB. Orthopnea w/ less than 3 pillows. Legs swollen, difficult to get out of bed. Slept poorly. Not eaten or opened bowels since admission.
O: Tc 99 Tm 100 HR 90 BP 110-140/62-80 Sats 94 2L O2 RR 14 I: +2000ml O: 3500 ml Net -1500 ml
O/E: AOx3 GCS 15
HEENT: PERLA, normal EOM neck supple, MMM
CV: RRR, no M/R/G, pitting edema to calves b/l
Resp: CTAB
Abdo: SNT BS tick, no masses
Labs: CBC
CMP
Enzymes
Coag
Imaging: EKG
CXR
Echo
Consults:
A/P: 49 y/o m with extensive cardiac risk factors and prior CAD w/ central cp and ekg/enzyme changes suggestive of MI
P 1.) MI:
1.)
2.)
3.)
2.) DM:
1.)
2.)
3.)
3.) HTN:
1.)
2.)
3.)
4.) Poor mobility:
1.)
2.)
3.)
5.) FENp:
1.) TEDS
2.) LMWH
3.) PPI
6.) Dispo:
1.) To home
Glossary:
PMH: Past medical history
CAD: Coronary artery disease
CABG: Coronary artery bypass disease
s/p: Status Post (i.e. done in the past)
Dx: Day x
Nitro: Nitroglycering/GTN
Lasix: Furosemide
Tc/Tm: Current temp and maximal temp
BPs: Given as ranges
AO: Alert and orientated (x1, x2, x3)
EOM: Extraocular movements
MMM: Moist mucous membranes
RRR: Respiratory rate regular
M/R/G: Murmurs, rubs or gallops
CTAB: Clear to Auscultation Bilaterally
CBC: Complete Blood Count/FBC
CMP: Complete Metabolic Panel (Na, K, Glucose, Urea, Creatine, Calcium, Magnesium, Phosphate)
Coag: Clotting
EKG: ECG
Dispo: Disposition
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