Other chest pain Coronary atherosclerosis of native coronary artery Aftercare following surgery for neoplasm Pure hypercholesterolemia Other acquired deformities of ankle and foot Other chest pain
 
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 tightness and left arm tingling
 
Major Surgical or Invasive Procedure:
None

 
History of Present Illness:
___ yo male with a history of CAD (2 DES placed into LAD on 
___, hyperlipidemia, HTN, and smoking history presenting 
with left chest tightness. On the day prior to admission, the 
patient felt a pressure in his left arm associated with 
calminess, diaphoresis, lightheadedness and weakness that lasted 
for a couple of hours. He does not recall if he took 
nitroglycerin. On the day of admission, the patient felt 
pressure in his left chest with associated lightheadednes. These 
episodes came on with rest. He said that these symptoms felt 
different from his last MI (during his old MI, he felt 
indigestion), but had a feeling that these symptoms were related 
to his heart.
.
The patient recalls one incident since his last cath when he 
felt indigestion (his anginal equivalent), but he took 
nitroglycerin and it went away. He also had a couple of other 
incidents, but cannot recall them.
.
On presentation to the ED, his vitals were T: 98.3 HR: 87 BP: 
130/64 RR: 18 O2 sat: 100%RA. The patient presented to the ED 
with ___ chest tightnes which was relieved with one SLNG and 
his tightness resolved in minutes. His first set of cardiac 
biomarker were within normal limits. His EKG was unchanged since 
prior. He took his home aspirin and Plavix before coming to the 
hospital. His CXR was unremarkable.
.
On review of systems, he denies any prior history of stroke, 
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the 
time of surgery, myalgias, joint pains, cough, hemoptysis, black 
stools or red stools. He denies recent fevers, chills or rigors. 
He denies exertional buttock or calf pain.
.
Cardiac review of systems is notable for absence of dyspnea on 
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, 
palpitations, syncope or presyncope.
.
On review of systems, the patient has said that since his NSTEMI 
that it has been difficult to lift his left foot and push off 
the ball of it when walking. He also feels numbness on the arch 
of his left foot. 
 
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: 2 drug eluting stents: 
proximal and mid LAD (___)
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
-cluster headache (no terrible headaches for years) 
 
Social History:
___
Family History:
No family history of arrhythmia, cardiomyopathies, or sudden 
cardiac death; otherwise non-contributory. His uncle and cousin 
died of MIs in their ___. 
 
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T=97.4 BP=134/86 HR=68 RR=18 O2 sat=100% RA
GENERAL: Pleasant thin male in NAD. Oriented x3. Mood, affect 
appropriate.
HEENT: NCAT. Sclera anicteric. ___, EOMI. Conjunctiva were 
pink, no pallor or cyanosis of the oral mucosa. No facial droop
NECK: Supple. JVP not elevated
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 
or S4. No chest wall tenderness
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no 
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Full range of motion 
of his extremities
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Neuro: Patient able to ambulate. Can walk on heels and balls of 
feet. CN II-XII intact. ___ strength and intact sensation in 
upper extremity. 2+ patellar/Achilles reflex in ___. ___ 
dorsiflexion in left foot, otherwise ___ has ___ strength. 
Decreased sensation in lateral aspect of left lower calf and 
wrapping onto arch of the foot, otherwise sensation normal. No 
babinski sign. No Romberg sign. No pronater drift. 
 
Pertinent Results:
Admission physical exam:

___ 11:45AM BLOOD WBC-5.7 RBC-4.57* Hgb-14.1 Hct-41.7 
MCV-91 MCH-30.7 MCHC-33.7 RDW-13.9 Plt ___
___ 11:45AM BLOOD Neuts-61.9 ___ Monos-6.0 Eos-5.3* 
Baso-0.4
___ 05:50AM BLOOD ___ PTT-32.2 ___

___ 11:45AM BLOOD Glucose-113* UreaN-14 Creat-0.7 Na-140 
K-4.3 Cl-105 HCO3-27 AnGap-12

Cardiac enzymes: 
___ 11:45AM BLOOD CK(CPK)-96 CK-MB-NotDone cTropnT-<0.01
___ 07:11PM BLOOD CK(CPK)-72 CK-MB-NotDone cTropnT-<0.01
___ 05:50AM BLOOD CK(CPK)-58 CK-MB-NotDone cTropnT-<0.01

Studies:

EKG: Sinus rhythm. Prior inferoposterior myocardial infarction. 
Compared to the previous tracing of ___ the rate has 
increased. Otherwise, no diagnostic interim change.

___
___

CXR: No acute intrathoracic process.

Stress Echo (___):
.
INTERPRETATION: A ___ y/o man s/p NSTEMI and stents ___ was 
referred to the lab for evaluation of chest pain. He exercised 
9.25 minutes of ___ protocol ___ METS) and stopped due to 
fatigue. This represents an excellent physical working capacity 
for his age. He denied any arm, neck, back or chest discomfort 
throughout the test. There were no significant ST segment 
changes throughout the study. The rhythm was sinus with no 
ectopy throughout the study. There was an appropriate blood 
pressure and heart rate response to exercise.
.
IMPRESSION: No ischemic EKG changes or anginal type symptoms. 
Echo report sent separately. 

Echo:

The patient exercised for 9 minutes 15 seconds according to a 
___ treadmill protocol ___ METS) reaching a peak heart rate 
of 142 bpm and a peak blood pressure of 156/54 mmHg. The test 
was stopped because of fatigue. This level of exercise 
represents a very good exercise tolerance for age. In response 
to stress, the ECG showed no diagnostic ST-T wave changes (see 
exercise report for details). There were normal blood pressure 
and heart rate responses to stress.

Resting images were acquired at a heart rate of 75 bpm and a 
blood pressure of 112/60 mmHg. These demonstrated normal 
regional and global left ventricular systolic function. Right 
ventricular free wall motion is normal. Doppler demonstrated no 
aortic stenosis, aortic regurgitation or significant mitral 
regurgitation or resting LVOT gradient.

Echo images were acquired within 56 seconds after peak stress at 
heart rates of 133 - 115 bpm. These demonstrated appropriate 
augmentation of all left ventricular segments with slight 
decrease in cavity size. There was augmentation of right 
ventricular free wall motion.

IMPRESSION: Very good functional exercise capacity. No ECG or 2D 
echocardiographic evidence of inducible ischemia to achieved 
workload.
Suboptimal study - sub-optimal image quality during 
post-exercise acquisitions.  
 
Brief Hospital Course:
Summary: ___ yo male with a history of CAD (2 DES placed into LAD 
on ___, hyperlipidemia, HTN, and smoking history presenting 
with left chest tightness.

CORONARIES: The patient has known CAD with a cath report from 
___ and an intervention with placement of 2 DES into the 
proximal and distal LAD (lesions were hazy though FFR showed 
pressure gradient difference). At that time, he only had single 
vessel disease. The patient presents with a different type of 
discomfort than his previous anginal pain. Cardiac enzymes x 3 
were normal and there were no EKG changes. The patient did not 
experience any discomfort during the hospitalization. He was 
continued on Plavix, high dose aspirin, lisinopril and a statin. 
A beta blocker was held because he had an adverse reaction to it 
in the past. Since his discomfort was different than his prior 
and his last cath was only 2 months ago, it was decided to 
perform a stress echo on the patient. The stress echo was normal 
revealing excellent physical endurance and a very good 
functional exercise capacity without ECG of 2D echo evidence of 
inducible ischemia. On discharge, the patient was given a 
prescription for sublingual nitroglycerin. He has a PCP 
appointment on ___ and ___ planned to have his PCP organize 
cardiology followup.
-follow cardiac enzymes
.
# Dyslipidemia: From ___ his lipid panel showed LDL calc: 
75, HDL: 41, ___: 122, Total choleterol: 122. He was advised to 
increase his simvastatin 10 mg dose for a goal of LDL<70. On 
discharge, the patient was given a prescription for pravastatin 
20 mg daily because it will provide cost savings. 

# Left foot drop and associated numbness: The patient complains 
of difficulty pushing on the ball of his left foot. The physical 
exam revealed ___ dorsiflexion of the foot and sensory loss on 
the lateral aspect of the calf wrapping on the the arch of the 
foot. He did not have any back or neck pain. The remainder of 
his neurological exam was normal. Since his symptoms are only 
distal, they might be due to compression of a nerve. He was 
given an appointment at the neurology urgent clinic for further 
evaluation. 

Outpatient followup:
1. Check LDL if at goal
2. Neurology for left foot weakness
 
Medications on Admission:
1. Clopidogrel 75 mg Daily
2. Aspirin 325 mg Daily
3. Verapamil 240 mg SR Daily PRN headaches (one tablet BID)
4. Lisinopril 5 mg daily
5. Simvastatin 10 mg qHS
6. Nitroglycerin 0.3 mg Tablet PRN chest pain
7. Flexeril PRN muscle spasm 
 
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  
3. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet 
Sustained Release PO twice a day as needed for headache.  
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  

5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, 
Sublingual Sublingual PRN (as needed) as needed for chest pain: 
___ repeat up to three times.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
6. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO QHS (once a 
day (at bedtime)).  
7. Flexeril 5 mg Tablet Sig: unknown dose Tablet PO PRN as 
needed.  
 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary
-atypical chest pain
-coronary artery disease
.
Secondary
-hypercholesterolemia

 
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent

 
Discharge Instructions:
You came to the hospital because you were having left arm 
tightness/numbness and also left chest tightness. There was 
concern that it was your heart. You also had a bout of 
indigestion since your last cath. Your bloodwork, EKG and stress 
echo showed no evidence of a heart attack.
.
You will be continued on the same medications. You should ask 
your primary care physician at your appointment on ___ about 
your cholesterol. In the past, your LDL was noted to be 76.
.
You have an appointment at the neurology clinic for your foot. 
They can further evaluate the reason why it's difficult to push 
off the ground.
 
Followup Instructions:
___

{'chest tightness': ['Other chest pain', 'Coronary atherosclerosis of native coronary artery'], 'left arm tingling': ['Other chest pain', 'Coronary atherosclerosis of native coronary artery'], 'pressure in his left arm': ['Other chest pain', 'Coronary atherosclerosis of native coronary artery'], 'calminess': ['Other chest pain', 'Coronary atherosclerosis of native coronary artery'], 'diaphoresis': ['Other chest pain', 'Coronary atherosclerosis of native coronary artery'], 'lightheadedness': ['Other chest pain', 'Coronary atherosclerosis of native coronary artery'], 'weakness': ['Other chest pain', 'Coronary atherosclerosis of native coronary artery'], 'difficulty pushing off the ground with left foot': ['Other acquired deformities of ankle and foot'], 'numbness in the arch of the foot': ['Other acquired deformities of ankle and foot']}