tokens: Admission Date : 2012-11-06 Discharge Date : 2012-11-11 Date of Birth : 1965-09-22 Sex : M Service : CCU HISTORY OF PRESENT ILLNESS : The patient is a 47 - year-old male with a past medical history of coronary artery disease , status post 2-vessel percutaneous transluminal coronary angioplasty in 2005 , 3-vessel percutaneous transluminal coronary angioplasty in 2009 , hypertension , new onset type 2 diabetes , and hypercholesterolemia who presents with the sudden onset of substernal chest pain status post exercise . The patient presented to Bournewood Hospital on the morning of admission with a chief complaint of substernal burning without radiation which developed while doing exercise . Of note , this is the second time the patient has exercised in many months . The pain became worse over the next few minutes to 07-12 and increased to 10-12 while he was in the ambulance . His nitroglycerin patch did not help , and he only had slight relief with sublingual nitroglycerin times three . In addition , he had slight shortness of breath but denies headache , change in vision , dizziness , nausea , vomiting , abdominal pain , change in bowel or urinary habits , or fevers , chills , and sweats . Of note , he had a negative stress test in 2012-07-03 . He was sent to Bournewood Hospital via ambulance . In the Emergency Department he received aspirin , nitroglycerin drip , heparin drip , Dilaudid , and TNK with decreased in his pain but without resolution of symptoms . Electrocardiogram at that time showed ST elevations and J point elevations in V2 through V4 . The patient was transferred to Sturdy Memorial where he underwent catheterization . Catheterization results showed 100% occlusion of the proximal left anterior descending artery and 50% stenosis of first diagonal . Angio-Jet percutaneous transluminal coronary angioplasty and stenting was performed on proximal left anterior descending artery and the percutaneous transluminal coronary angioplasty was performed on first diagonal with good results . An intra-aortic balloon pump was placed at this time as well . PAST MEDICAL HISTORY : 1. Coronary artery disease ; the patient is status post percutaneous transluminal coronary angioplasty times three in 2009 at Clinton Hospital ; the patient is status post percutaneous transluminal coronary angioplasty times two in 2005 at Waltham/Weston Hospital . 2. Type 2 diabetes . 3. Hypercholesterolemia . 4. Hypertension . FAMILY HISTORY : The patient 's father died of a myocardial infarction at age 40 , and a brother who died of a myocardial infarction at age 40 . SOCIAL HISTORY : No ethanol use . No tobacco at this time ; he quit 20 years ago . The patient is married . MEDICATIONS ON ADMISSION : Diltiazem 180 mg p.o. q.d. , Lipitor 10 mg p.o. q.d. , Glyset 25 mg p.o. q.d. , Prevacid 30 mg p.o. q.d. , metoprolol 50 mg p.o. b.i.d. , Glucophage 500 mg p.o. q.d. ALLERGIES : Allergies included PENICILLIN and IODINE . PHYSICAL EXAMINATION ON ADMISSION : Temperature maximum 98.7 , temperature current 98.3 , pulse ranged from 82 to 92 , blood pressure 104 to 124/67 to 74 with a mean of 86 to 99 , respiratory rate of 11 to 16 , oxygen saturation 94% to 98% on 2 liters . Pulmonary artery pressure was 29/15 with a mean of 22 . Cardiac output was 7 ( that was on 6 of dopamine ) . Intra-aortic balloon pump augmented systole was 109 , augmented diastole was 111 . The patient was lying flat in no apparent distress . HEENT revealed extraocular movements were intact . Pupils were equal , round , and reactive to light and accommodation . The oropharynx was clear with moist mucosa . Neck was supple . No lymphadenopathy . Lungs were clear to auscultation bilaterally , anteriorly and laterally . Cardiovascular revealed jugular venous distention not appreciated . Carotids had normal upstroke and normal volume with bilateral bruits . A regular rate . Normal S1 and S2 . No S3 or S4 . No murmurs , rubs or gallops . Abdomen had decreased bowel sounds , soft , nontender , and nondistended . No hepatosplenomegaly . Liver was about 5 cm . Extremities had no edema . The right groin revealed intra-aortic balloon pump site and pulmonary artery catheterization site were clean , dry and intact without tenderness . Dorsalis pedis pulses were 2+ bilaterally . Neurologic examination revealed alert and oriented times three . Cranial nerves II through XII were intact . LABORATORY DATA ON ADMISSION : Laboratories on admission revealed white count 7.8 , hematocrit was 41.7 , platelets of 252 , MCV 89 , RDW 12.7 . Chem-7 revealed sodium of 136 , potassium 4.7 , chloride 103 , bicarbonate 22 , BUN 16 , creatinine 0.8 , glucose 284 . PT 14.2 , PTT 108.5 , INR 1.3 . Creatine kinase at 11 a.m. was 83 , at 5 p.m. was 3021 . Arterial blood gas at 11 a.m. was 7.33/46/115 . Creatine kinases trended from 11:15 on the day of admission from 83 to 3021 at 5 p.m. to 3450 at 11 p.m. , to 1734 at 5:30 a.m. on 11-07 , to 1277 at 11:30 a.m. on 11-07 , to 83 at 9:30 a.m. on 11-11 . RADIOLOGY / IMAGING : Electrocardiogram post catheterization showed continued ST elevations and J point elevations in V2 through V3 . Post catheterization echocardiogram showed an ejection fraction of 30% , moderate systolic dysfunction , basal anterior hypokinesis , mid anterior akinesis , basal anteroseptal hypokinesis , mid anteroseptal akinesis . Anterior apex akinesis , inferior apex akinesis , and apex akinesis . The was trace mitral regurgitation and trace tricuspid regurgitation . IMPRESSION : This is a 47 - year-old male with a past medical history of type 2 diabetes , high cholesterol , hypertension , and coronary artery disease , status post percutaneous transluminal coronary angioplasty times two , who presented with acute coronary syndrome refractory to medical treatment and TNK , now status post Angio-Jet percutaneous transluminal coronary angioplasty and stent of proximal left anterior descending artery and percutaneous transluminal coronary angioplasty of first diagonal with intra-aortic balloon pump placement . HOSPITAL COURSE : The Mass. Mental Health Center hospital course was unremarkable . Dopamine was discontinued on day one . The intra-aortic balloon pump was discontinued on day two . The patient was continued on heparin throughout his hospital course and transitioned to Coumadin on hospital day four . The patient was continued on Lipitor and aspirin , and Plavix was added and will be continued for 30 days post catheterization . The patient was continued on Lopressor and captopril throughout his hospital course , and changed to Zestril 10 mg q.d. and atenolol 25 mg q.d. at discharge . The patient was discharged to the medical floor on hospital day three and discharged from the hospital once his INR was within the 2 to 2.5 range . CONDITION AT DISCHARGE : The patient 's condition on discharge was stable . DISCHARGE STATUS : He was discharged home . DISCHARGE FOLLOWUP : Instructions to follow up with his primary care physician on the Heather after discharge . Primary care physician was to check INR and titrate Zestril up and atenolol as tolerated . MEDICATIONS ON DISCHARGE : 1. Lipitor 10 mg p.o. q.d. 2. Aspirin 325 mg p.o. q.d. 3. Plavix 75 mg p.o. q.d. times 30 days . 4. Prevacid 30 mg p.o. q.d. 5. Atenolol 25 mg p.o. q.d. 6. Zestril 10 mg p.o. q.d. 7. Glyset 25 mg p.o. q.d. 8. Glucophage 500 mg p.o. q.d. 9. Coumadin 5 mg p.o. q.d. Tina Squillace , M.D. 30-977 Dictated By : Lloyd U. King , M.D. MEDQUIST36 D : 2012-11-12 21:57 T : 2012-11-15 14:05 JOB # : 15711 cc : Beau J. Box , M.D.