tokens: 814743340 RWH 3393103 501370 9041109 5/13/2006 12:00:00 AM Discharge Summary Unsigned DIS Report Status : Unsigned DISCHARGE SUMMARY NAME : TRICHEPRAKEJESC , BETLA UNIT NUMBER : 381-75-78 ADMISSION DATE : 05/13/2006 DISCHARGE DATE : 05/16/2006 PRINCIPAL DIAGNOSIS : Chest pain . ASSOCIATED DIAGNOSIS : Coronary artery disease ; hypertension ; hyperlipidemia ; sleep apnea ; diabetes type 2 . PROCEDURES : Adenosine stress test . Part 1 of a sleep study . Coronary angiogram . Chest CT . Chest x-ray . HISTORY AND REASON FOR HOSPITALIZATION : The patient is a 55-year-old gentleman with a history of CAD status post non ST elevation MI in 11/17 who presents with chest pain X 48 hours . He went to Padrugmoff Hospital Emergency Room . He has a history of hypertension , diabetes , and high cholesterol . In 2003 , he had a non ST elevation MI , came to the RWH , and had a cath done , which showed a 40% RCA , which was hazy . An IVUS was done , and it was felt that it was more severe . He underwent a PTC stenting of an RCA with a Vision stent , 3 x 18 . Diagonal 1 also had a 99% stenosis . There was no other noted disease . Since then , the patient has occasional chest pain with emotional stress , when he is angry or upset . Yesterday morning , he developed intermittent substernal chest pain with radiation to the left shoulder that worsened with any activity and any motion of his shoulders . It progressed over the course of the day requiring less movement . He also became short of breath with climbing a flight of stairs . He denies diaphoresis or nausea . He went to the Padrugmoff Hospital Emergency Room after trying nitroglycerin at home . However , his nitroglycerin was old and the script was expired . In the ER , he received 3 sublingual nitroglycerins and 1 mg of Dilaudid . After that , he was pain-free . Lopressor IV was given to control his heart rate . He also received Lipitor 80 mg , Plavix 300 , heparin IV , integrelin double bolus , followed by a drip . Apparently once his pain was free , his EKG was noted to have hyperacute T-wave anteriorly without progression . He was transferred to the Ro Woodma Healthcare for further cardiac care . PAST MEDICAL HISTORY : Diabetes ; hypertension ; hyperlipidemia . MEDICATIONS AT HOME : Include Lisinopril 5 mg p.o. every day ; nitroglycerin sublingual p.r.n.; Toprol XL 100 mg p.o. every day ; Plavix 75 mg p.o. every day ; Avandia 4 mg p.o. every day ; Lipitor 40 mg p.o. every day ; TriCor 145 mg p.o. every day . SOCIAL HISTORY : He is married . He does have a lot of anxiety . Socially he drinks alcohol . He does not smoke . He has 2 daughters . HOSPITAL COURSE : The patient ruled out for an MI with negative CK X4 and negative troponin X4 . He was taken to the Cardiac Catheterization Lab where cath showed top-normal LVEDP at 12 ; no AF ; widely patent RCA stent ; mild CAD in the left coronary artery symptom ; widely patent diagonal 1 at the site of prior PTCA . He received an Angio-Seal to the right common femoral artery . He then underwent a CT scan to rule out a PE . That test was negative . He underwent lower extremity study to rule out a DVT in both legs . That was negative . He was noted to have an episode of desaturation into the 80% range while sleeping . Pulmonary consult was done , and it was felt that the patient should undergo a formal sleep study , full PFTs , and a repeat CT scan in 1 year to assess for pulmonary nodule that was seen . However , please note that this nodule has been stable over time . The patient also complained of intermittent right neck swelling , and recommendations are to consider a CT scan with contrast to evaluate nodes in his neck . On physical exam today , the patient did not have any swelling , and he states that he did not feel the swelling was present . The patient underwent an adenosine stress test , where he exercised for 4 minutes , reaching 65% of predicted heart rate . He did not have chest pain . EKG was negative for ischemia . The myocardial perfusion images show no definite evidence of ischemia . The LV contractile function was normal . There was mild posterior vasal thinning . It is not clearly outside normal limits . He underwent an echocardiogram , which showed an EF of 60% . There was no evidence of MVP . There was trace mitral regurgitation . There was no evidence of LA dilatation . There was no aortic stenosis . There was trace aortic insufficiency . The LV cavity size was normal . The systolic function was within normal limits . There was no evidence of LV hypertrophy . There was no obvious segmental wall-motion abnormality . There was no evidence of pericardial effusion . The right ventricle was not dilated . The systolic function was within normal limits . The patient underwent a sleep study , the first part , which showed that he had 75 respiratory events observed with apnea , hypopnea index of 11 an hour . The mean heart rate was 68 . They felt that there was obstruction and possible obstruction to airflow generating some obstructive apnea , as well as partial obstructive events . They recommended that the patient may benefit from a trial of continuous positive pressure at the bedside . The patient has been scheduled to have the second part of the sleep study done on June 18 , 2006 , at 8:30 p.m. at RWH in the Esley Community Hospital , 10th floor sleep lab , phone number 133-225-1257 . Prior to discharge today , he underwent PFTs . The results of the PFTs are unavailable at the time of this dictation . Based on all the tests above , it was felt that the patient was stable for discharge home . His blood pressure was 114 to 123/62 . Heart rate 69 to 80 . Room air saturation 96% . Temperature 97.9 . Lung sounds clear bilaterally . Heart sounds : Regular rate and rhythm ; S1-S2 ; positive S4 ; no murmur . Abdomen : Soft , nontender , nondistended ; no guarding ; no masses ; positive bowel sounds X4 . Right groin status post catheterization showed no hematoma or bruit . Lower extremity pulses were intact without any edema . Lab values : Sodium 139 ; potassium 4.1 ; BUN 15 ; creatinine 1.1 ; magnesium 1.6 ; SGPT 19 ; SGOT 20 ; alkaline phosphatase 66 ; total bilirubin 0.6 ; direct bilirubin 0.2 ; total cholesterol 234 ; triglycerides 274 ; HDL 44 ; LDL 135 ; hemoglobin A1c 6.7 ; white cell count 6.1 ; hematocrit 36.4 ; platelet count 201 . During the hospital course , the patient was started on a PPI , Nexium , for concerns of acid reflux . Also , a long discussion was taken with the patient as most of his chest discomfort happens when he is quite anxious . He used Ativan in the hospital , which helped him . The patient was advised that he needs to speak with his PCP about medication for antianxiety and / or further testing or counseling to help control his anxiety level . MEDICATIONS ON DISCHARGE : Nitroglycerin 1 tablet sublingual q. 5 minutes X3 p.r.n. chest pain . TriCor 145 mg p.o. every day . Lipitor 40 mg p.o. every day . Plavix 75 mg p.o. every day . Aspirin 325 mg p.o. every day . Lisinopril 5 mg p.o. every day . Avandia 4 mg p.o. every day . Toprol XL 100 mg p.o. every day . Prilosec 20 mg p.o. every day . Ativan 0.5 mg p.o. b.i.d. p.r.n. anxiety . The patient was asked to follow up with his PCP , Dr. Cora Belbsnil , at Necrestneysagiles Medical Center in a period of 1 to 2 weeks . He was asked to follow up with Dr. Riale Tables , his cardiologist , in a period of 1 to 2 weeks ; he also works at Necrestneysagiles Medical Center . The patient was told that he should discus with his PCP further GI testing , as well as medications for anxiety . The patient will need to have a followup sleep study done as above per the recommendations based on the results . CONDITION ON DISCHARGE : Stable . RYROL DALEDAE , NP DICTATING FOR : Unreviewed _____________________________ NAA NARICHA EARLY , M.D. TR : so DD : 05/16/2006 TD : 05/17/2006 7:29 A 501370 cc : NAA NARICHA EARLY , M.D.