Non-ST elevation (NSTEMI) myocardial infarction Dissection of abdominal aorta Gastro-esophageal reflux disease without esophagitis Encounter for immunization Long term (current) use of antithrombotics/antiplatelets Long term (current) use of aspirin
 
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
Chest pain
 
Major Surgical or Invasive Procedure:
___ - Percutaneous coronary intervention with thrombectomy 
and no stent 

 
History of Present Illness:
Mr. ___ is a healthy ___ year-old male who presented with 
back pain and chest pain following a crossfit work-out and was 
found to have a dissection of the abdominal aorta in addition to 
new q waves on EKG and a mildly elevated troponin. The patient 
reports that he had a strenuous work-out the morning of 
admission. At home, shortly following the work-out, he 
experienced acute onset back pain across his back below the 
clavicle. This was associated with a cold sweat. The pain did 
not subside and when the patient tried to climb his stairs at 
home, he felt extremely week and thus presented to the ___ at 
___. Upon presentation his back pain began to subside 
but he did begin to experience some mild central chest pain. 

At the ___, he was hemodynamically stable. An EKG was 
obtained which demonstrated new inferior q waves and a troponin 
was measured at 0.04. A CTA was obtained which demonstrated an 
abdominal aortic dissection of the infrarenal aorta. He was 
therefore transferred to ___ for further care. 

Here CT repeated â still no ascending dissection.  Overnight 
echocardiogram poor quality, no obvious WMA.  This morningâs 
echo showed slight inferior HK.  Cardiac biomarkers rising and 
pt noted to have Q waves with slight STEs inferiorly. 

He went to cath and was found to have a RCA lesion. He had a 
thrombectomy with no stent and has a 50% residual distal RCA 
stenosis. Admitted to the CCU for further monitoring.

Vitals on transfer were: T  98.2, HR 63, BP 123/71, RR 21, 99% 
RA.

On the floor, patient reports that he feels "great" with no 
chest pain, back pain, shoulder pain or SOB. Only complaint is 
of mild lower abdominal dull pain.

 
Past Medical History:
PCP ___ ___ EKG with first-degree heart block sinus 
bradycardia, pt is asymptomatic, no further actions
GERD  
L4/L5 microdiscectomy  
Otherwise healthy
 
Social History:
___
Family History:
Father: angioplasty, afib
Mother: afib
___ grandfather may have had MI
Otherwise mainly history of cancer (lung)
No family history of early MI, arrhythmia, cardiomyopathies, or 
sudden cardiac death; otherwise non-contributory.  
 
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T  98.2, HR 63, BP 123/71, RR 21, 99% RA
Gen: Pleasant gentleman, NAD
HEENT: MMM
NECK: no JVP elevation
CV: RRR, no murmurs, rubs, gallops
LUNGS: CTAB, no wheezes
ABD: soft, +BS, mild tenderness in mid lower quadrant
EXT: warm, well-perfused, +pulses
SKIN: warm, dry, no rashes or lesions
NEURO: A&Ox3, CNII-XII grossly intact

DISCHARGE PHYSICAL EXAM:
========================
VS: T 98.2, HR 60-70s, BP 120s/70s, RR ___, 97-99% RA
Gen: Pleasant gentleman, NAD
HEENT: MMM
NECK: no JVP elevation
CV: RRR, no murmurs, rubs, gallops
LUNGS: CTAB, no wheezes
ABD: soft, +BS, mild tenderness in mid lower quadrant
EXT: warm, well-perfused, +pulses
SKIN: warm, dry, no rashes or lesions
NEURO: A&Ox3, CNII-XII grossly intact
 
Pertinent Results:
Admission Labs:
===============
___ 06:15PM BLOOD WBC-11.3* RBC-4.61 Hgb-13.4* Hct-40.5 
MCV-88 MCH-29.1 MCHC-33.1 RDW-12.9 RDWSD-41.2 Plt ___
___ 06:15PM BLOOD Neuts-76.8* Lymphs-15.5* Monos-7.2 
Eos-0.0* Baso-0.2 Im ___ AbsNeut-8.67* AbsLymp-1.75 
AbsMono-0.81* AbsEos-0.00* AbsBaso-0.02
___ 06:15PM BLOOD ___ PTT-27.9 ___
___ 06:15PM BLOOD Glucose-99 UreaN-15 Creat-1.0 Na-137 
K-4.1 Cl-102 HCO3-27 AnGap-12
___ 12:19AM BLOOD CK(CPK)-2278*
___ 06:15PM BLOOD CK-MB-52*
___ 12:19AM BLOOD Calcium-8.8 Phos-2.9 Mg-2.0

Discharge Labs:
===============
___ 06:40AM BLOOD WBC-6.1 RBC-4.14* Hgb-11.9* Hct-37.3* 
MCV-90 MCH-28.7 MCHC-31.9* RDW-12.8 RDWSD-42.0 Plt ___
___ 06:40AM BLOOD ___ PTT-28.4 ___
___ 06:40AM BLOOD Glucose-92 UreaN-13 Creat-0.9 Na-138 
K-4.1 Cl-101 HCO3-26 AnGap-15
___ 10:45AM BLOOD CK(CPK)-713*
___ 06:40AM BLOOD Calcium-9.3 Phos-4.3 Mg-2.0
___ 04:55AM BLOOD %HbA1c-5.2 eAG-103
___ 11:26AM BLOOD Triglyc-627* HDL-65 CHOL/HD-2.6 
LDLmeas-73
___ 04:24AM BLOOD CRP-2.8

Troponin Trend:
===============
___ 06:15PM BLOOD cTropnT-0.21*
___ 12:19AM BLOOD CK-MB-157* MB Indx-6.9* cTropnT-0.70*
___ 03:58AM BLOOD CK-MB-178* MB Indx-7.3* cTropnT-1.37*
___ 09:58AM BLOOD CK-MB-171* MB Indx-6.7* cTropnT-1.82*
___ 04:24AM BLOOD cTropnT-2.77*
___ 11:26AM BLOOD CK-MB-3 cTropnT-<0.01

CK Trend:
=========
___ 12:19AM BLOOD CK(CPK)-2278*
___ 03:58AM BLOOD CK(CPK)-2432*
___ 09:58AM BLOOD CK(CPK)-2562*
___ 11:26AM BLOOD CK(CPK)-74

Micro:
=======
RPR: 

Imaging:
=========
CTA ___:
1.  Infrarenal abdominal aortic aneurysm as detailed above 
originating at the level of the ___ and extending into the 
proximal right common iliac artery.  No significant change 
compared to recent CT. 
2.  Normal thoracic aorta without dissection. 

CXR ___:
Lungs are fully expanded and clear.  Cardiomediastinal and hilar 
silhouettes and pleural surfaces are normal. 

EKG (___):  
NSR, nl axis, no ST changes 

TTE (___):  
The left atrium is mildly dilated. No atrial septal defect is 
seen by 2D or color Doppler. Left ventricular wall thickness, 
cavity size and regional/global systolic function are normal 
(LVEF >55%). There is no ventricular septal defect. Right 
ventricular chamber size and free wall motion are normal. An 
aortic dissection cannot be excluded. The aortic valve leaflets 
(3) appear structurally normal with good leaflet excursion and 
no aortic stenosis or aortic regurgitation. The mitral valve 
leaflets are structurally normal. Mild (1+) mitral regurgitation 
is seen. The pulmonary artery systolic pressure could not be 
determined. There is no pericardial effusion. 

CARDIAC CATH (___):  RCA occluded with thrombus in mid- to 
distal-vessel. LAD and circumflex free of disease.

 
Brief Hospital Course:
___ y/o previously healthy gentleman presenting with a type B 
aortic dissection complicated by an NSTEMI in the context of a 
cross-fit workout.

# CORONARIES:  50% distal RCA occlusion, LAD and circumflex 
clean 
# PUMP:  EF > 55%
# RHYTHM:  normal

#) TYPE B AORTIC DISSECTION: Mr. ___ is a healthy ___ 
year-old male who presented with back pain and chest pain 
following a crossfit work-out and was found to have a dissection 
of the abdominal aorta. The dissection was located just beneath 
the takeoff of the ___, and terminating at the proximal most 
aspect of the right
common iliac artery. Although he is a male he has no other clear 
risk factors, including HTN, age, CAD, vasculitis, bicuspid 
aortic valve, family history, h/o AVR, or cocaine use. We 
continued tight BP control - SBP<140 with IV/PO BB. He had no 
evidence on exam or imaging of end-organ or lower extremity 
ischemia. Therefore, the is no indication for emergent vascular 
surgery intervention. He will need f/u imaging in 6 months and 
will follow up with ___. His ESR and CRP were 
within normal limits and his RPR was not reactive.

#) ACUTE CORONARY SYNDROME:  
He went to cath and was found to have a RCA lesion. He had a 
thrombectomy with no stent and has a 50% residual distal RCA 
stenosis. Admitted to the CCU for further monitoring after 
thrombectomy and we continued heparin 24h after procedure 
(starting
it 4 hours after procedure). The patient is a Killip Class I 
indicating 6% mortality based on an updated study in JAMA 
performed at ___ and ___ published in 
___. We continued aspirin 81mg daily, ticagrelor 90 BID, 
atorvastatin 10mg daily.

TRANSITIONAL ISSUES:
=========================
[] f/u aortic imaging in 6 months

 
Medications on Admission:
None.
 
Discharge Medications:
1. TiCAGRELOR 90 mg PO BID 
RX *ticagrelor [BRILINTA] 90 mg 1 tablet(s) by mouth twice a day 
Disp #*60 Tablet Refills:*6
2. Atorvastatin 80 mg PO QPM 
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 
Tablet Refills:*6
3. Aspirin EC 81 mg PO DAILY 
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet 
Refills:*6
4. Metoprolol Succinate XL 12.5 mg PO DAILY 
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth 
daily Disp #*30 Tablet Refills:*6
5. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 
RX *nitroglycerin 0.4 mg 1 tablet(s) sublingually q5min Disp 
#*15 Tablet Refills:*0

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary diagnosis:
- TYPE B AORTIC DISSECTION 
- ACUTE CORONARY SYNDROME

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

 
Discharge Instructions:
Dear Mr. ___,

You came to the hospital because you were having chest pain. We 
found that you were having a heart attack and we broke down a 
clot from one of your hearts blood vessels to treat that. Other 
imaging found that the wall of your large blood vessel, the 
aorta had formed a slit called a dissection. The vascular 
surgeons and did not think you needed to have a surgical repair 
at this time. It will be very important for you to keep good 
control of your blood pressure, and follow-up with the vascular 
surgeons, your PCP, and your new cardiologist (Drs. ___ 
and ___.  

Should you have any chest pain, please use the nitroglycerin 
pills we have prescribed for you. Take up to three pills, spaced 
5 minutes apart. If the pain does not go away after this, call 
___. If your pain does go away, call either Dr. ___ Dr. 
___ an appointment.

Finally, we have started you on several new medications because 
of your heart attack. These are very important, and must be 
taken every day. They are:

1) Ticagrelor (Brillinta) 90 mg twice a day. This will be 
continued for at least 3 months, and potentially as long as 9 
months. The duration of this will be decided in follow-up 
appointments with Dr. ___
2) Aspirin 81 mg daily, likely for the forseeable future
3) Metoprolol succinate 12.5 mg daily, on an ongoing basis
4) Atorvastatin 80 mg daily, on an ongoing basis

It was a pleasure taking care of you!
Your ___ Team
 
Followup Instructions:
___

{'Chest pain': ['Non-ST elevation (NSTEMI) myocardial infarction', 'Dissection of abdominal aorta'], 'Back pain': ['Dissection of abdominal aorta'], 'Cold sweat': ['Non-ST elevation (NSTEMI) myocardial infarction', 'Dissection of abdominal aorta'], 'Extremely week': ['Non-ST elevation (NSTEMI) myocardial infarction', 'Dissection of abdominal aorta'], 'Mild lower abdominal dull pain': ['Dissection of abdominal aorta']}