Subendocardial infarction initial episode of care Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Tobacco use disorder
 
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
chest pain
 
Major Surgical or Invasive Procedure:
cardiac catheterization with DES to LAD
 
History of Present Illness:
___ yoM with PMH of hypercholesterolemia, cluster H/A, tobacco 
use admitted with NSTEMI.  Patient had episode of chest pressure 
and dyspnea awakening from sleep at 3am.  No associated 
diaphoresis and nausea, no vomiting or other symptoms.  Pressure 
lasted approximately 1 hr, so patient presented to ED.  
In ED, VS 167/74 46 20 100% on RA.  Given SLN x 1, morphine and 
GI cocktail with resolution of symptoms.  Initial EKG with NSR; 
q waves in II, III, AVF; nonspecific ST changes in precordial 
leads.  First troponin negative, second elevated to 0.50.  
Patient given ASA 325mg, loaded with 600mg plavix, started on 
heparin and integrilin drip.  Emergent cardiac catheterization 
with DES to proximal 50% and distal 70% LAD stenosis.    
On transfer to floor, VS 84  150/90   100%on RA.  Patient 
comfortable, without further chest pain, palpitations, SOB or 
other complaints.  On review of systoms, patient denies history 
of exertional angina or dyspnea, dizziness, palpitations, PND, 
orthopnea, peripheral edema.  No history of fevers, chills, 
cough, dark or tarry stool, exertional buttock or calf pain.  Of 
note, patient denies any cardiac history.  Exercise stress test 
earlier this year just notable for elevated BP.

 
Past Medical History:
1.CARDIAC RISK FACTORS: Dyslipidemia, Hypertension  
2. OTHER PAST MEDICAL HISTORY: cluster H/A  

 
Brief Hospital Course:
___ yoM with PMH of hypercholesterolemia, tobacco use admitted 
with NSTEMI s/p catheterization with serial DES to LAD.

1. NSTEMI: Admitted with chest pain that woke patient from sleep 
at 3:30am and lasted approximately 3 hours. Multiple risk 
factors for CAD including HTN, hyperlipidemia, current tobacco 
use and age.  EKG with equivocal ST abnormalities in right 
precordial leads. Second set of troponin/CKMBs positive. 
Received aspirin, plavix and started on heparin and integrilin 
drips.  Cardiac catheterization found 2 serial LAD lesions ___ 
and mid) and 3.0mm Promus stents placed 
(non-overlapping/spot-stenting).  Patient had no immediate 
complications.  ECHO showed normal biventricular cavity sizes 
with preserved global and regional biventricular systolic 
function.  The patient remained chest pain free throughout 
hospitalization. Patient started on aspirin 325mg daily 
indefinately, plavix 75mg daily for at least one year. Recommend 
reduction of risk factors via lifestyle modification and 
medication management.  Importance of smoking cessation was 
especially stressed.   

2. HTN: Patient was continued on his home medications of 
verapamil SR 240mg and lisinopril 5mg with target BP < 130/80.  
Although patient would benefit from a B-blocker, he suffers from 
cluster headaches and has a compelling reason to be on calcium 
channel blocks.  

3. Hyperlipidemia: Fasting lipid panel on admission showed total 
cholesterol: 140 HDL: 41 LDL: 75.  Given NSTEMI, patient was 
placed on simvastatin 80mg during hospitalization.  Discharged 
on home dose of stain although this should be uptotrated as 
outpatient to reach goal LDL < 70.  

 
Medications on Admission:
verapamil SR 240mg daily  
zocor 10mg daily  
lisinopril (?) 5mg daily  

 
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Verapamil 120 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 
hours).  
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  

5. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime.  
6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)  
Sublingual see below as needed for chest pain: take 1 every 5 
minutes (up to 3 tablets) until pain resolves.
Disp:*30 tablets* Refills:*0*

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary Diagnosis:
NSTEMI

Secondary Diagnosis:
HTN
dyslipidemia

 
Discharge Condition:
good: hemodynamically stable, chest pain free

 
Discharge Instructions:
You were admitted after an episode of chest discomfort and 
shortness of breath.  These were symptoms of a heart attack, or 
a non- ST elevated myocardial infarction.  You were treated with 
a cardiac catheterization, where 2 drug eluting stents were used 
to open blockages in your LAD, an artery in your heart.  After 
this procedure, you will need to take aspirin 325 mg daily 
indefinately and plavix 75 mg for at least ___ year to prevent a 
new clot from forming in your stents.  You should refrain from 
strenuous activity and heavy lifting for ___ days.  
It is also important for you to be compliant with your other 
medications to reduce your risk of having another heart attack 
in the future.  You blood pressure and lipid levels will be 
followed closely by your primary care physician.  You need to 
stop smoking.

Please make the following changes to your medications:
1. Please take Aspirin 325 mg daily
2. Please take plavix 75 mg daily
Please take all of your other medications as previously 
prescribed.
Note: your dose of simvastatin may have to be adjusted by your 
primary care physician based on your fasting lipid panel.  This 
test is pending at the time of discharge and will be sent to 
your doctor.

If you develop chest pressure, shortness of breath, bleeding, 
redness or pain at your right groin, new rash, confusion, fever, 
or any other concerning symptom please call your physician or 
return to the emergency department.
  
 
Followup Instructions:
___

{'chest pain': ['Subendocardial infarction', 'Coronary atherosclerosis of native coronary artery'], 'dyspnea': ['Subendocardial infarction', 'Coronary atherosclerosis of native coronary artery'], 'hypercholesterolemia': ['Pure hypercholesterolemia'], 'tobacco use': ['Tobacco use disorder']}