tokens: Admission Date : 2014-10-14 Discharge Date : 2014-10-17 Date of Birth : 1959-12-09 Sex : M Service : CCU HISTORY OF PRESENT ILLNESS : This is a 55 - year-old Caucasian speaking male who is a smoker and has a family history of coronary artery disease , as well as a personal history of hypertension , who experienced multiple episodes of 10/10 substernal chest pain radiating down his left arm last night with his daily activities . Each episode lasted approximately 15 minutes in duration and resolved on their own . This morning while landscaping the patient had unremitting 12-05 pain with shortness of breath and diaphoresis . He presented to Deaconess-Nashoba Hospital Hospital and the first EKG was found to have ST elevations in V1-V3 of 1-2 mm with T wave inversions in V4-6 , I and L , which progressed to 3-0167 W. Seventh Ave. elevations within 20 minutes . Heparin and nitroglycerin drip were started with 10 mg of IV Retavase half dose . He was transferred to the North Adams Regional Hospital for catheterization . Once at Hahnemann General Hospital he received heparin and Integrilin . Coronary angiography revealed left main , left circumflex and RCA normal and left LAD with 99% midstenosis . A Hepacoat stent was placed with no residuals but good flow after nitroglycerin and diltiazem . The chest pain persisted afterwards and a relook catheterization was performed that revealed no occlusions . The right heart catheterization revealed a cardiac output index of 4.11 and 2.15 respectively . RA pressure was 13 , RV pressure 45/7 , wedge 27 and PA pressures of 42/21 . He was transferred to the CC for monitoring and he denied having further pain , shortness of breath , nausea or vomiting . At baseline the patient denies any previous chest pain , pressure , dyspnea on exertion , orthopnea , PND or palpitations . PAST MEDICAL HISTORY : Only hypertension . MEDICATIONS : Antihypertensive medications that the patient could not identify . ALLERGIES : The patient denies having any drug allergies . FAMILY HISTORY : Significant for a brother who had an MI at age 61 . SOCIAL HISTORY : He has two kids , works as a landscaper and as a school custodian in Ware . He has a 15 to 20 pack-year history . Smokes 1 pack-per-day for 15 years but had quit for 20 years and recently restarted . He drinks two glasses of wine per day and denies any use of illicit substances . PHYSICAL EXAMINATION ON ADMISSION : The patient was afebrile . Blood pressure 156/67 , pulse 80 and respiratory rate 14 . Appearance : He was laying flat , very tense . Skin was strong build and was in no apparent distress . HEENT : He was anicteric with moist mucous membranes . No JVD or increased JVP was appreciated at 0 degrees . The patient did not have any carotid bruits , abdominal bruits or femoral bruits . His PMI was two finger breath width in the fifth intercostal space lateral to the midclavicular line . There were no lifts or heaves on examination . His heart was regular with no murmurs , rubs or gallops and his radial and DP pulses were both 2+ bilaterally and equal . His lungs were clear to auscultation . His abdomen was scaphoid , nondistended , nontender with positive bowel sounds . His extremities were warm , pink with no edema . The right calf site had minimal ooze and no hematomas or bruits . ELECTROCARDIOGRAM : Significant for what was stated in the HPI . OVERALL IMPRESSION : This is a 54 - year-old man with significant coronary artery disease risk factors , positive family history , smoking history , hypertension and gender who presented with an ST elevation MI status post LAD stent , complicated by no residuals requiring nitroglycerin and diltiazem for good flow . The patient was pain free and doing well . HOSPITAL COURSE : For his coronary artery disease , aspirin was started at 325 . Plavix was started at 75 mg a day , Lipitor 20 mg per day , metoprolol 25 mg twice a day to be titrated up as tolerated and on day two of admission an ACE inhibitor was started . Captopril 6.2 3 x a day and titrated up . A lipid panel was checked and found to be within normal limits , although it was noted this was in the post MI setting and the lipid panel could be falsely low . Serial CK s were followed with a CK peak of 433 . Hypertension was managed with beta blocker and ACE inhibitor and Integrilin was continued post MI for 18 hours . Rhythm was maintained at normal sinus , monitored on telemetry without ectopy . EKG s were followed for normalization . The patient had an echocardiogram on day two of admission , which revealed a mildly dilated left atrium , mild symmetric LVH , normal LV cavity size , mild region LV systolic dysfunction , arresting regional wall motion abnormality including focal apical hypokinesis , a normal right ventricular chamber size and free wall motion , a moderately dilated aortic root , a mildly dilated ascending aorta , normal aortic valve leaflet , normal mitral valve leaflet and no pericardial effusions . The patient was normal volume and displayed no evidence CHF signs or symptoms . The risk factors were addressed . The patient was told repeatedly that he needed to stop smoking and was given a nicotine patch and his primary care provider was called to discuss outpatient plans to help the patient stop smoking . The patient was advised to have a low fat / low cholesterol diet , was cleared by PT and advised to do cardiac rehabilitation . He was advised the importance of each of his and compliance with each of these medications and was told he needed close followup with a cardiologist . For renal , his creatinine was monitored and the dye load and the catheterization . It was normal and did not increase . Gastrointestinal : The patient was given a low fat / low cholesterol diet . His electrolytes were monitored and repleted carefully . He had normal bowel movements and had GI prophylaxis throughout his stay . For hematology , the patient 's hematocrit and platelets were monitored after the catheterization . They were normal and did not change and the patient received pneumatic boots for DVT prophylaxis . On day two of admission , the patient ambulated with PT and was moved to the regular floor . On day three of admission , the patient felt that his strength was back to baseline . He denied ever having any chest pain , chest pressure , shortness of breath , dyspnea on exertion and he was discharged to home . He was told to return to the emergency department if he had any chest pain , pressure , difficulty breathing , nausea , light-headiness or dizziness . He was advised to take all of his medications . An appointment was established for him to see his primary care doctor , Dr. Stella Booth on Maynard , 2014-10-20 and the patient was referred to Dr. Granville Hamers , at Ware in cardiology to be seen in two weeks . Dr Marcus assistant was called and she stated that she would call the patient with an appointment . FINAL DIAGNOSES : 1. ST elevation myocardial infarction . 2. Hypertension . MAJOR SURGICAL AND INVASIVE PROCEDURES : Cardiac catheterization and stent placement in the mid left anterior descending artery . DISCHARGE CONDITION : Good . DISCHARGE MEDICATIONS : Aspirin 325 mg q.d. , Plavix 75 mg q.d. , Lipitor 20 mg q.d. , nitroglycerin 0.3 mg sublingually p.r.n. chest pain or pressure or shortness of breath , lisinopril hydrochlorothiazide 20 / 12.5 mg q.d. , atenolol 25 mg q.d. The patient was told he could return to work after two weeks of rest , given that his work required a high level of exertion and the patient was also given a prescription for a transdermal nicotine patch 14 mg the be used for up to 2 weeks until cravings remitted . Antonio PINTO , M.D. 52-057 Dictated By : Salvador BX Hernandez , M.D. MEDQUIST36 D : 2014-10-18 12:39 T : 2014-10-21 12:42 JOB #: 78572 Signed electronically by : DR. Steve PINTO on : SUN 2014-11-02 8:39 PM ( End of Report )