Acute myocardial infarction of inferolateral wall initial episode of care Esophageal reflux Other and unspecified hyperlipidemia Depressive disorder not elsewhere classified Long-term (current) use of aspirin
 
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
Chest Pain
 
Major Surgical or Invasive Procedure:
cardiac catheterization

 
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:  
.
___ yo female presented to ___ today with chest pain.  She 
awoke this AM with burning substernal chest pain.  The pain 
radiated to her neck, shoulders, left arm and back.  She denies 
associated shortness of breath, nausea, or diaphoresis.  She 
reports she had a very similar episode 8 months ago which 
resolved with rest.  She reports similar but less severe chest 
pain during exercise.  Her vital signs on arrival to ___ 
were 97.8, 98, 154/75, and 99% on RA.  She was found to have ST 
elevations inferiorly, II, III, aVR and laterally, V5, V6, with 
reciprocal changes in V1, V2, V3, I, aVL.  The patient was given 
nitro, plavix 600mg, aspirin 325mg, 4600units of heparin bolus, 
8mg of morphine, and zofran.  She was air lifted to ___ for 
further management.
.
In the cath lab, she was found to have non-obstructive coronary 
artery disease.  She was found to have a LAD ostial lesion that 
was not thought to be causing her EKG changes.  She did have 
basal inferior wall motion abnormalities.  Upon further 
questioning she reported she has been going through a stressful 
time in her life with the death of an uncle and the attempted 
suicide of her daughter.  ___ diltiazem 1mg was 
attempted to improve vasospasm as Takotsubos was suspected.  She 
received metoprolol 10mg IV during the case for sinus 
tachycardia.
.  
On arrival to the CCU, the patient is asymptomatic and vital 
signs stable.
.
On review of systems, she 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. She denies recent fevers, chills or 
rigors. She denies exertional buttock or calf pain. All of the 
other review of systems were negative.  
.  
Cardiac review of systems is notable for absence of dyspnea on 
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, 
palpitations, syncope or presyncope.  
.
 
Past Medical History:
1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia, 
(-)Hypertension  
2. CARDIAC HISTORY:  none
-CABG:  none
-PERCUTANEOUS CORONARY INTERVENTIONS:  none
-PACING/ICD:  none
3. OTHER PAST MEDICAL HISTORY:  
Depression
.  
.  

 
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or 
sudden cardiac death; otherwise non-contributory.  
 
Physical Exam:
VS: HR 67 BP 132/83 RR 14 O2 95%
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.  
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were 
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.  

NECK: Supple with JVP not elevated.  
CARDIAC: PMI located in ___ intercostal space, midclavicular 
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or 
S4.  
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp 
were unlabored, no accessory muscle use. CTAB, no crackles, 
wheezes or rhonchi.  
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not 
enlarged by palpation. No abdominial bruits.  
EXTREMITIES: Right groin angioseal in place, dressing clean dry 
intact, no femoral bruit or hematoma. No edema.  
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+  
.  

 
Pertinent Results:
CK(CPK) AlkPhos Amylase TotBili DirBili IndBili 
___          242*           
___          441*           
___          832*           
___          1127*           
___          1127* 
 CK-MB MB Indx cTropnT 
___    10 4.1 1.57*1 
___    24* 5.4 1.29*1 
___    73* 8.8* 1.47*1 
___    118* 10.5*   
___    138*2 12.2* 1.42*___ORONARIES:  Her initial EKG changes were thought to be 
consistent with inferior wall STEMI, however no obstructing 
lesions were seen on cardiac cath.  Her V-gram on cath revealed 
what looked like apical and inferior wall hypokinsesis.  Given 
the history of excess stress, and this v-gram our working 
diagnosis was Takotsubos cardiomyopathy.  However, when her EKG 
did not return to baseline, and she developed inferior q waves 
it was determined that she had an inferior MI with autolysis and 
early presentioin. She was started on aspirin, high dose 
atorvastatin, beta-blocker, and ACE-inhibitor for her STEMI.  
She did not have an intervention and was not started on plavix.  

.  
# PUMP:  Her wall motion abnormalities were thought to be ___ 
ischemia with some contribution of stunning and myocyte death.  
Her EF was oreserved on ECHO.
.  
# RHYTHM:  The patient had an episode of sinus tachycardia in 
the cath lab and received metoprolol 10mg IV.  Her heart rate 
remained well controlled on metoprolol throughout her stay.  
.
#GERD: Ms ___ had chest pain intermittently throughout the 
stay.  Her EKGs were not consistent with cardiac source.  It was 
relieved by maalox, and she was started on omeprazole for 
suppression.
.
# Hypercholesterolemia:  Given her STEMI her new LDL goal will 
be 70.  Towards that end and also in accordence the PROVE-IT 
trial she was started on 80mg of Atorvastatin.
.  
# Depression:  We continued her zoloft and he was seen by an in 
house social worker to help her cope with both her life 
stressors and her new disease. 
.  
FEN: She was kept on a Heart Healthy diet. 
.
PROPHYLAXIS:  
DVT ppx was acheived with heparin SC TID 
Pain management was acheived with tylenol and oxycodone PRN
Bowel regimen was acheived with colace and senna PRN

 
Medications on Admission:
lipitor 10 mg
amlodipine 10 mg
atenolol 25 mg
 
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) 
2. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).  
3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical 
QID (4 times a day) as needed for itching.  
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).
5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H 
(every 12 hours) for 5 days.
6. Vicodin ___ mg Tablet Sig: ___ Tablets PO every four (4) 
hours as needed for pain.
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) 
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO once a day.  
9. Xanax 0.25 mg Tablet Sig: One (1) Tablet PO twice a day as 
needed for anxiety.  
10. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a 
day.
Disp:*30 Tablet(s)* Refills:*2*

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
ST Elevation Myocardial Infarction
Depression
Hyperlipidemia

 
Discharge Condition:
Mental Status:Clear and coherent
Activity Status:Ambulatory - Independent

 
Discharge Instructions:
You had a heart attack that damaged a small portion of your 
heart. Your heart function was slightly compromised. A cardiac 
catheterization did not show any signs of blockages or 
narrowings of the coronary arteries. A cardiac MRI was done and 
results are pending at this time.
You will be started on new medicines to prevent another heart 
attack and help your heart recover from this one. Please get a 
blood pressure cuff and check your blood pressure at home, keep 
a log to show to your doctors. 
___ changes:
1. Start Aspirin 325 mg every day to prevent blood clots
2. Start Metoprolol 12.5 mg mg twice daily to lower your heart 
rate and prevent another heart attack
3. Start Lisinopril, this is to lower your blood pressure and 
help your heart recover.
4. Start Atorvastatin to lower your cholesterol
5. Start Vicodin to treat the chest pain, take only as needed
6. Start omeprazole to prevent heartburn. You can try to stop 
this when the chest pain is gone. 
7. Start ciprofloxacin to treat your urinary infection. You will 
need a total of 7 days, take until all pills are gone. 
8. STOP taking Pravastatin
.

 
Followup Instructions:
___

{'Chest pain': ['Acute myocardial infarction of inferolateral wall'], 'Radiated pain': ['Acute myocardial infarction of inferolateral wall'], 'ST elevations': ['Acute myocardial infarction of inferolateral wall'], 'Non-obstructive coronary artery disease': ['Acute myocardial infarction of inferolateral wall'], 'Basal inferior wall motion abnormalities': ['Acute myocardial infarction of inferolateral wall'], 'Takotsubos cardiomyopathy': ['Acute myocardial infarction of inferolateral wall'], 'Inferior MI with autolysis and early presentioin': ['Acute myocardial infarction of inferolateral wall'], 'Depression': ['Depressive disorder'], 'Hypercholesterolemia': ['Other and unspecified hyperlipidemia'], 'GERD': ['Esophageal reflux']}