tokens: Admission Date : 2015-10-05 Discharge Date : 2015-10-08 Date of Birth : 1815-10-05 Sex : F Service : MEDICINE Allergies : Shellfish Attending : Jacob U. Rolland , M.D. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 91 yo woman with h/o HTN who came from Bridgewater State Hospital Rehab with substernal chest pain after exercise . Pt had been in her usual state of health and performed here regular exercises . After returning to her room she w noted SSCP without radiation . No nausea , vomiting , diaphoresis . They did an ECG at Bridgewater State Hospital rehab which demonstarted new ST depressions in V1-V4 . She received ASA 81 mg x 2 and nitro SL x 2 with partial relief at nursing home . On presentation to Providence Behavioral Health Hospital Amanda , her vitals were HR 68 , BP 142/68 , RR 28 , O2 sat 100% RA . Exam was notable for RRR with no murmur , bibasilar crackles , guaiac negative . EKG showed sinus brady , with old LAD and new ST depressions in V1-V4 . Troponin was 0.07 . She received ASA , nitro SL then gtt , morphine , metoprolol , and heparin gtt . Cardiology discussed cath however , patient 's family turned down . Transferred to CCU for further management and observation . Past Medical History: HTN Hearing difficulty Blindness 02-26 macular degeneration R ankle fx 2002 S/p hysterectomy Social History : currently lives at Bridgewater State Hospital Rehab; no tobacco or EtOH use; used to be housewife Family History : n/c Physical Exam: Vitals : T 97.8 , HR 53 , BP 156/58 , RR 16 , O2 sat 94% on 2.5 L Gen : NAD , awake , alert , blind , able to hear loud voices at L ear HEENT : MMM , OP clear Neck : JVP 11 cm CV : Reg rate , nl S1 & S2 , no m/r/g Pulm : Crackles at base and mid-lungs bilaterally Abd : Soft , NT , ND , BS present , no masses Ext : Trace ankle edema bilaterally Pertinent Results: LABS on admission: WBC - 11.4* RBC - 3.61* Hgb - 11.4* Hct - 32.6* MCV - 90 MCH - 31.7 MCHC - 35.1* RDW - 14.7 Plt Ct - 281 Glucose - 124* UreaN - 30* Creat - 1.3* Na - 137 K - 4.2 Cl - 102 HCO3 - 27 AnGap - 12 CK ( CPK ) - 42 cTropnT - 0.07* . STUDIES: EKG : sinus brady @ 48 bpm , LAD , LVH , RBBB , Q wave in I , ST depressions in V1-V4 , ST elevation in III , aVF , TWI in III , V5 . CXR 10-07 : There is slight worsening of the still mild pulmonary edema . There is no pneumothorax . Small right pleural effusion is stable . Cardiac size is normal . Echo : LVEF >70% , LA 6.1 cm , no regional wall motion abnormality . Cardiac Enzymes 2015-10-05 09:00PM BLOOD CK ( CPK ) - 1471* CK-MB - 207* MB Indx - 14.1* cTropnT - 6.00* 2015-10-06 04:47PM BLOOD CK ( CPK ) - 1288* CK-MB - 158* MB Indx - 12.3* cTropnT - 6.88* 2015-10-07 07:30AM BLOOD CK ( CPK ) - 627* CK-MB - 55* MB Indx - 8.8* cTropnT - 4.46* . Labs on Discharge 2015-10-08 08:35AM WBC - 13.8* RBC - 3.39* Hgb - 10.7* Hct - 30.2* MCV - 89 MCH - 31.5 MCHC - 35.3* RDW - 14.8 Plt Ct - 214 Glucose - 120* UreaN - 30* Creat - 1.2* Na - 134 K - 4.2 Cl - 100 HCO3 - 25 AnGap - 13 Calcium - 8.7 Phos - 2.5* Mg - 2.1 Brief Hospital Course: INITIAL IMPRESSION : 90 year-old woman with h/o of HTN p/w substernal chest pain shortly after exercise at nursing home , with EKG showing ST depressions in V1-V4 and troponin 0.07. Likely NSTEMI . . HOSPITAL COURSE BY SYSTEM : . * CV : The patient 's family refused coronary artery catheterization . The patient was given ASA , Plavix , heparin drip x 24 hours , nitro drip , atorvastatin , metoprolol , and lisinopril . Her chest pain was controlled with morphine . Her SBP remained in the 160s-170s on hospital day 1 and she was gently diuresed . On hospital day 2 she experienced atrial fibrillation with HR in the 140s . Her metoprolol dose was increased from 25 mg PO bid to 50 mg PO bid then 75 mg PO tid . Her HR decreased to 70s-80s . Her BP remained stable . An ECHO showed that she had preserved EF and no wall motion abnormalities . We decided given her age that she would not be a good candidate for cardioversion for her afib nor would she be a good candidate for coumadin . Therefore we will continue rate control with metoprolol this can be titrated if needed , and aspirin and plavix for anti-coagulation . She should also continue on lipitor and lisinopril . She should have her chem 7 checked next week given the start of her new meds . Will also need LFT 's checked in 3-6 months . . * Pulmonary : Bilateral crackles at bases and midlungs , elevated JVP , trace bilateral ankle edema , and CXR with diffuse opacities suggest possible pulmonary edema , likely secondary to acute MI . Her O2 sat was stable at 94-97% on 2.5L of supplemental O2 . She experienced no respiratory difficulty during the hospital stay . She was diuresed small amount . Her CXR prior to discharge showed mild pulm edema and thus was given 40 of lasix prior to going to rehab . She can be given prn lasix for weight gain or shortness of breath . . * Leukocytosis- She developed mild elevated WBC . UA had 12-14 WBC 's , few bacteria . She was initially started on Bactrim , but this was stopped as she was afebrile . SHe has a culture pending which needs to be followed up at the nursing home and treated if positive . . * Code : DNR/DNI Medications on Admission : tylenol PRN lisinopril 5 mg PO qd protonix 20 mg PO qd artifical tears bid metoprolol 25 mg PO bid Discharge Medications: 1. Senna 8.6 mg Tablet Sig : One ( 1 ) Tablet PO BID ( 2 times a day ) as needed . 2. Docusate Sodium 100 mg Capsule Sig : One ( 1 ) Capsule PO BID ( 2 times a day ) as needed for constipation . 3. Aspirin 325 mg Tablet Sig : One ( 1 ) Tablet PO DAILY ( Daily ) . 4. Clopidogrel 75 mg Tablet Sig : One ( 1 ) Tablet PO DAILY ( Daily ) . 5. Atorvastatin 80 mg Tablet Sig : One ( 1 ) Tablet PO DAILY ( Daily ) . 6. Pantoprazole 40 mg Tablet , Delayed Release ( E.C. ) Sig : 0.5 Tablet , Delayed Release ( E.C. ) PO Q24H ( every 24 hours ) . 7. Polyvinyl Alcohol 1.4 % Drops Sig : 1-2 Drops Ophthalmic BID ( 2 times a day ) . 8. Lisinopril 10 mg Tablet Sig : One ( 1 ) Tablet PO DAILY ( Daily ) . 9. Metoprolol Tartrate 25 mg Tablet Sig : Three ( 3 ) Tablet PO TID ( 3 times a day ) . 10. Acetaminophen 325 mg Tablet Sig : Two ( 2 ) Tablet PO BID ( 2 times a day ) . 11. Maalox 225-200 mg/5 mL Suspension Sig : Five ( 5 ) mL PO every six ( 6 ) hours as needed for indigestion . 12. Lasix 40 mg Tablet Sig : One ( 1 ) Tablet PO once a day as needed for shortness of breath or wheezing : Can give 40 lasix PO if having any weight gain or shortness of breath . Discharge Disposition: Extended Care Discharge Diagnosis: NSTEMI Atrial Fibrillation HTN Discharge Condition: Patient without chest pain , heart rate and BP stable . Discharge Instructions: Please take all medications as instructed . She has been started on several new medications which are important to protect her heart . If the patient experiences any chest pain , shortness of breath , nausea , vomiting , fevers , chills , please return to the emergency room . Followup Instructions: Please call ( 881-6997 to set up follow up cardiology appointment in 2-3 months . Betty Herbert MD 43-075 Completed by : Allison Crystal MD 52-741 2015-10-08 @ 1510 Signed electronically by : DR. Dorothy Z. Alderman on : SUN 2015-10-11 11:49 AM ( End of Report )