Date:
Patient:
Admitting Diagnosis: ST-elevation myocardial infarction (STEMI)
Subsequent Diagnoses: (e.g., Heart failure, arrhythmias)
HPI (History of Present Illness):
Summarize the patient’s presentation, including:
Onset, duration, location, and character of chest pain (crushing, pressure, radiating)
Associated symptoms (e.g., nausea, diaphoresis, shortness of breath)
Risk factors for coronary artery disease (CAD) (e.g., hypertension, hyperlipidemia, smoking history, diabetes)
Prior history of CAD or myocardial infarction (MI)
PMH (Past Medical History):
Relevant medical history including:
Comorbidities (e.g., hypertension, diabetes, hyperlipidemia)
Cardiovascular history (e.g., CAD, prior MI, peripheral vascular disease)
Medications (e.g., antihypertensives, statins, antiplatelets)
Allergies
Physical Exam:
Vital signs (including BP and heart rate)
General appearance (e.g., diaphoresis, pallor)
Cardiovascular exam (heart sounds, S3 gallop, JVD)
Respiratory exam (rales)
Labs:
CBC (complete blood count)
Basic metabolic panel (electrolytes, renal function)
Cardiac enzymes (Troponin I/T) – trend over time
Coagulation studies (if considering PCI)
Lipid panel (may be obtained later)
Imaging:
ECG (electrocardiogram) – note location and extent of ST-elevation
Chest X-ray (may show signs of heart failure)
Echocardiogram (to assess wall motion abnormalities and ejection fraction)
Coronary angiography (if indicated for intervention)
Procedure: (if performed)
Percutaneous coronary intervention (PCI) with stent placement
Coronary artery bypass graft (CABG) surgery
Diagnosis:
STEMI with involvement of (specify coronary artery territory)
Plan:
Acute Management:
Oxygen therapy (if hypoxia present)
Pain management with medications (e.g., morphine)
Antiplatelet therapy (e.g., aspirin, clopidogrel)
Anticoagulation therapy (if undergoing PCI)
Beta-blocker therapy (if tolerated)
Nitrates (if appropriate)
Long-term Management:
Cardiac rehabilitation
Lifestyle modifications (diet, exercise, smoking cessation)
Medications to optimize cholesterol, blood pressure, and heart function
Progress Notes:
Document daily progress including:
Response to treatment (improvement in symptoms, vitals)
Changes in medication regimen
Complications (e.g., arrhythmias, heart failure)
Mobilization and activity level
Discharge Planning:
Medications and refills
Follow-up appointments with cardiologist
Cardiac rehabilitation program
Education on risk factor modification and signs/symptoms of recurrent ischemia
Note: This is a template and should be adapted to the specific patient’s presentation, course of treatment, and interventions