Coronary atherosclerosis of native coronary artery Other and unspecified hyperlipidemia Unspecified essential hypertension Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Old myocardial infarction Percutaneous transluminal coronary angioplasty status
 
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
seasonal 
 
Attending: ___
 
Chief Complaint:
Lightheadedness
 
Major Surgical or Invasive Procedure:
Cardiac catheterization
 
History of Present Illness:
___ with h/o CAD s/p stents x2 in ___, on ASA + Plavix, who 
presents with one week of lightheadedness, fatigue, right 
shoulder pain, and shortness of breath (SOB). He reports that 
the fatigue/SOB occurs after 1 flight of stairs, which is 
abnormal for him. He also had symptoms with lifting boxes at 
work. In regards to the shoulder discomfort, he describes it as 
a "hollow feeling" in his right shoulder without frank pain, 
with some extension into the right arm. His symptoms improve 
with SL nitro. There is no particular pattern with exertion, but 
sometimes it wakes him up at night. He also reports some 
intermittent epigastric pain which he reports is how his prior 
MI presented, but currently not associated with activity. He 
denies any peripheral edema. He has had sclerotherapy recently 
for ganglion cyst in his leg and held Plavix about 1 month ago 
for that.

In the ED, initial vitals were T 97.6 HR 78 BP 125/70 RR 16 SaO2 
99% on RA. Labs and imaging significant for normal CBC, Chem 10, 
and troponin. EKG: NSR at 67 bpm with Q waves in III and aVF, 
similar to baseline.

Vitals on transfer were T 98.2 BP 160/87 HR 87 RR 18 SaO2 98% on 
RA. On arrival to the floor, patient reports some epigastric 
discomfort and right arm discomfort similar to before.

REVIEW OF SYSTEMS:  
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. All of the other 
review of systems were negative.

Cardiac review of systems is as above.
 
Past Medical History:
1. CAD 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)
-Left leg tibial/fibula ganglion cyst
-BPH
 
Social History:
___
Family History:
No family history of cancer, arrhythmia, cardiomyopathies, or 
sudden cardiac death. His uncle and cousin died of MIs in their 
___.
 
Physical Exam:
Admission:
GENERAL: WDWN in NAD.Oriented x3. Mood, affect appropriate.
VS: T 98.2 BP 160/87 HR 87 RR 18 SaO2 98% on RA
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were 
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple without elevation of JVP cm.
CARDIAC: RRR, no murmurs, rubs or gallops.
LUNGS: CTAB
ABDOMEN: Soft, non-tender, not distended. No HSM or tenderness. 
Abd aorta not enlarged by palpation. No abdominial bruits.
EXTREMITIES: No clubbing, cyanosis or edema.  2+ ___ pulses
NEURO: CN II-XII grossly intact, moving all extremeties, 
sensation grossly normal. Gait not tested.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.

Discharge
Vitals: T 97.6 BP 140/90 HR 75 RR 18 SaO2 100% on RA
NECK: Supple without elevation of JVP cm.  
CARDIAC: RRR; no murmurs, rubs or gallops.
LUNGS: CTAB
EXTREMITIES: No clubbing, cyanosis or edema.  2+ ___ pulses
 
Pertinent Results:
___ 12:00PM   WBC-4.7 RBC-4.58* HGB-14.6 HCT-44.2 MCV-97 
MCH-31.8 MCHC-32.9 RDW-13.8
___ 12:00PM   NEUTS-62.6 ___ MONOS-6.2 EOS-4.3* 
BASOS-0.5
___ 12:00PM   PLT COUNT-184
___ 12:00PM   ___ PTT-28.6 ___

___ 05:57AM   WBC-4.9 RBC-4.55* Hgb-14.2 Hct-43.5 MCV-96 
MCH-31.3 MCHC-32.7 RDW-13.6 Plt ___

___ 12:00PM   GLUCOSE-93 UREA N-21* CREAT-0.9 SODIUM-140 
___ 05:57AM   Glucose-95 UreaN-17 Creat-0.9 Na-140 K-4.6 
Cl-103 ___ 05:57AM   Calcium-9.3 Phos-3.2 Mg-2.2
HCO3-28 AnGap-14

___ 12:00PM                      cTropnT-<0.01
___ 06:50PM   CK(CPK)-80 CK-MB-3 cTropnT-<0.01
___ 05:57AM   CK(CPK)-81 CK-MB-2 cTropnT-<0.01

ECG ___  11:05:56 AM
Sinus rhythm. Prior inferior myocardial infarction. Compared to 
the previous tracing of ___ no diagnostic interim change.

CHEST (PA & LAT) ___ 2:10 ___
The cardiomediastinal, pleural and pulmonary structures are 
unremarkable. There is no pleural effusion or pneumothorax. No 
focal airspace consolidation is seen to suggest pneumonia. Heart 
size is normal. There are mild degenerative changes of thoracic 
spine, with anterior osteophytosis.

Cardiac catheterization ___   
1.  Selective coronary angiography of this left dominant system 
demonstrated no angiographically apparent, flow-limiting 
coronary artery disease. The LMCA was normal in appearence. The 
LAD stents were widely patent with no significant flowing 
limiting lesions. The dominant LCx had no significant lesions. 
The RCA was small, non-dominant with no significant luminal 
narrowing.
2.  Limited resting hemodynamics revealed normal left 
ventricular filling pressures, with an LVEDP of 5mmHg. The was 
no transvalvular gradient to suggest aortic stenosis. The was 
normal systemic blood pressure, with a central aortic pressure 
of 113/72 mmHg.
 
Brief Hospital Course:
___ yo man with history of CAD s/p drug-eluting stenting of 
proximal and mid LAD in ___, now presenting with right arm 
discomfort, epigastric pain, fatigue, and shortness of breath 
with exertion.

# Arm discomfort, fatigue, dyspnea: Symptoms were concerning for 
unstable angina given new onset over past week, though symptoms 
were predominantly on exertion and resolve with rest. Of note, 
he does have some epigastric discomfort which is a similar 
presentation to his prior MI. However, troponins were negative 
and EKG unchanged. Coronary angiography revealed no 
flow-limiting lesions and in particular no in-stent restenosis 
or thrombosis. Unclear what was causing his shortness of breath 
with right arm discomfort, but small vessel ischemia or 
diastolic dysfunction could not be excluded; he was already on 
dual anti-platelet therapy, ACE-I, and a calcium channel 
blocker. We continued his Plavix (although not clear he needs 
this ___ years S/P DES). Atorvastatin was begun to avoid drug-drug 
interactions with simvastatin. He would also benefit from a 
beta-blocker for post-infarct secondary prevention given prior 
NSTEMI in ___, but we deferred substitution of his veramapil 
for a beta-blocker to his outpatient cardiologist.

# Hypertension: continued on ACE-I and verapamil

# BPH: Continued on alfuzosin 
# CODE: full  
# EMERGENCY CONTACT: wife ___ number: ___ 
Cell phone: ___ 

Transitions of care:
-follow up with outpatient cardiology.
 
Medications on Admission:
alfuzosin 10 mg po daily
Plavix 75 mg daily
cyclobenzaprine 10 mg TID PRN
lisinopril 5 mg daily
ranitidine 300 mg po daily
simvastatin 80 mg po daily
verapamil 240 mg ER daily
aspirin 325 mg daily
MVI
Omega 3/vitamin E
 
Discharge Medications:
1. alfuzosin 10 mg Tablet Extended Release 24 hr Sig: One (1) 
Tablet Extended Release 24 hr PO daily ().
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).
3. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO three 
times a day as needed for muscle spasm.
4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO once a 
day.
6. verapamil 240 mg Tablet Extended Release Sig: One (1) Tablet 
Extended Release PO once a day.
7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Omega 3  Oral
10. vitamin E  Oral
11. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime. 
Disp:*30 Tablet(s)* Refills:*0*
 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Chest pain without biomarker evidence of myonecrosis
Coronary artery disease with prior myocardial infarction
Hypertension
Benign prostatic hypertrophy
 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
 
Discharge Instructions:
It was a pleasure participating in your care at ___. You were 
admitted to the hospital for chest pain. Cardiac catheterization 
was re-assuring that there was no blockage in your coronary 
arteries. 

REGARDING YOUR MEDICATIONS...
Medications STARTED that you should continue:
atorvastatin

Medications STOPPED this admission: 
simvastatin

Medication DOSES CHANGED that you should follow:
NONE

Otherwise, it is very important that you take all of your usual 
home medications as directed in your discharge paperwork.

Please followup with your primary care physician ___ ___ 
days regarding the course of this hospitalization.
 
Followup Instructions:
___

{'Lightheadedness': ['Coronary atherosclerosis of native coronary artery', 'Old myocardial infarction'], 'Fatigue': ['Coronary atherosclerosis of native coronary artery', 'Old myocardial infarction'], 'Right shoulder pain': ['Coronary atherosclerosis of native coronary artery', 'Old myocardial infarction'], 'Shortness of breath': ['Coronary atherosclerosis of native coronary artery', 'Old myocardial infarction'], 'Epigastric pain': ['Coronary atherosclerosis of native coronary artery', 'Old myocardial infarction'], 'Hollow feeling in right shoulder': ['Coronary atherosclerosis of native coronary artery', 'Old myocardial infarction']}