tokens: 7901625 Admission Date : 2015-03-16 Discharge Date : 2015-03-19 Date of Birth : Sex : Service : HISTORY OF PRESENT ILLNESS : The patient is an 82 - year-old male with a history of hypertension , remote tobacco abuse , chronic renal insufficiency , and a history of a TIA who was in his usual state of health until five nights prior to admission when he awoke at midnight with severe epigastric pain radiating to both arms . He also had bilateral arm numbness . The symptoms were associated with diaphoresis and shortness of breath but no nausea or vomiting . After approximately one hour , he presented to the Bristol County Tuberculosis Hospital Dana-Farber Cancer Institute Campus where he ruled in for a non-ST elevation MI with a CK of 438 with a peak CK MB of 19.8 and troponin that peaked at 10.2 . He was started on nitrates there as well as heparin and Integrelin and remained pain-free . He denied any history of similar symptoms in the past and has had no prior history of angina or myocardial infarction . The patient was subsequently transferred to Youville Hospital for cardiac catheterization . At the time of transfer , he was initially admitted to the CMI Service after undergoing cardiac catheterization which revealed a long LAD lesion that was angioplastied without stent placement , and a total occlusion of the RCA with collaterals . He subsequently became hypotensive and bradycardiac in the Catheterization Laboratory which responded to IV fluids , dopamine , Atropine , and he was then transferred to the CCU for further monitoring . He had a bedside transthoracic echocardiogram done in the Cardiac Catheterization laboratory without evidence of an effusion . A Swan was also placed . There were no stents deployed at all throughout the catheterization . By the time he was admitted , he was off pressors and hemodynamically stable and pain-free . PAST MEDICAL HISTORY : TIA in 1998 . COPD with 2 liters dependence of home 02 . BPH . Chronic renal insufficiency . Gastritis . Asthma . SOCIAL HISTORY : He lis currently widowed . He lives in senior apartment housing in Cambridge on the second floor . He is very active . He uses a cane p.r.n. for walking . He denied any falls at home . His only family member is a niece in Missouri . He is currently retired . He has a remote tobacco history and reports occasional alcohol use . He denied any other drug use . FAMILY HISTORY : Noncontributory . ALLERGIES : The patient has no known drug allergies . MEDICATIONS ON ADMISSION : 1. Aspirin 325 mg q.d. 2. Metoprolol 50 mg b.i.d. 3. Lipitor 10 mg q.d. 4. MDI p.r.n. 5. Heparin drip on transfer . 6. Integrelin drip on transfer . PHYSICAL EXAMINATION : Vital signs : Heart rate 91 , regular , blood pressure 169/81 from a right groin A line , respirations 12 , oxygen saturation of 97 percent on 2 liters nasal cannula . General : He was a well appearing male in no acute distress . HEENT : Crusting around the right eyelid but the pupils were equal , round , and reactive to light . He was edentulous . Neck : The neck was supple without lymphadenopathy or thyromegaly . Cardiovascular : His heart was regular with a normal S1 and S2 . He had no murmurs , rubs , or gallops . Lungs : His lungs were clear to auscultation bilaterally Anteriorly and laterally . Abdomen : Soft , obese , nontender , nondistended . He had normoactive bowel sounds . Extremities : There was a right groin A line and a left groin venous sheath with a Swan . He had no evident edema . He had 2+ dorsalis pedis and posterior tibial pulses bilaterally . Neurologic : He was alert and oriented times three , moving all extremities . LABORATORY DATA : On admission , the CBC revealed a white count of 7.4 , hematocrit 39.7 , and platelets of 217,000 . Serum chemistries revealed a sodium of 135, potassium 4.0 , chloride 102 , bicarbonate 26 , BUN 29 , creatinine 1.6 , and glucose of 111 . The initial EKG showed normal sinus rhythm at a rate of 71 with a normal axis and evidence of first-degree AV block with prolonged PR interval of 238 milliseconds . He also had a widened QRS of 153 milliseconds , an old right bundle branch block , and no acute ST or T wave changes . The EKG was prior to catheterization and the one post PTCA was no different . He had a bedside echocardiogram done in the Catheterization Laboratory which showed normal LV wall thickness and normal LV cavity size . There was no evidence of effusion . It was difficult to assess free wall motion . Cardiac catheterization revealed a totally occluded RCA with collaterals , an 80 percent LAD lesion extending distally which was angioplastied but no stent was placed . Hemodynamics : The right heart catheterization revealed pulmonary capillary wedge pressure of 4 , cardiac output of 8 , and cardiac index of 3.8 , he had an RA pressure of 10 , RV pressure of 43/4 , PA pressure of 37/10 . ASSESSMENT : This is an 82 - year-old male with a history of prior tobacco use , hypertension , chronic renal insufficiency , COPD , gastritis , and TIA who initially presented to Braintree with a non-ST elevation MI and Guaiac positive stools , transferred to St. Margaret's Center for Women & Infants for cardiac catheterization with PTCA to mid LAD lesion complicated by hypotension and bradycardia requiring Atropine , IV fluids and transient dopamine possibly secondary to vagal reaction , subsequently transferred to CCU for close monitoring , hemodynamically stable at the time of admission to the CCU . HOSPITAL COURSE : 1. CARDIOVASCULAR : As summarized above , the patient had a non-ST elevation MI with evidence of an 80 percent mid LAD lesion for which he underwent angioplasty without stent placement . He was initially continued on aspirin , Plavix , beta blocker , statin , and ACE inhibitor . At the time of discharge , his Plavix was held due to Guaiac positive stools and hematocrit drop throughout admission . He had a transthoracic echocardiogram the day after admission showing an ejection fraction of greater than 60 percent . No focal wall motion abnormalities . He had no recurrent chest pain or shortness of breath throughout admission . In regards to his rhythm , he has an underlying right bundle branch block and first-degree AV block which were stable throughout this admission . He will be followed-up by his cardiologist after discharge . 1. PULMONARY : He had a history of COPD for which he is on baseline 2 liters of 02 by nasal cannula at home and Albuterol and Atrovent MDI s p.r.n. at home . He is also on Flovent MDI at home as well . He was continued on his MDI and was at his baseline 02 requirement throughout admission . 1. RENAL : He has a history of chronic renal insufficiency likely secondary to hypertension and was admitted with a creatinine of 1.6 . His ACE inhibitor post MI was initially held due to his creatinine . However , this responded to IV fluids and his ACE inhibitor was restarted at the time of discharge . He will need close monitoring of his creatinine post discharge in the setting of reinstitution of his ACE inhibitor . 1. GASTROINTESTINAL : His stools were noted to be Guaiac positive at the outside hospital and there was still concern for possible GI bleed given continued Guaiac positive stools during this admission and a slight drop in his hematocrit from 39 to 33 . It was felt most appropriate for him to have an outpatient GI workup , and his PCP was contacted and will arrange for outpatient colonoscopy . His Plavix was held at the time of discharge due to a question of GI bleed and in the setting of not having a stent placed at the time of catheterization . He was continued on his aspirin , however . DISCHARGE DIAGNOSIS : Coronary artery disease , status post non-ST elevation myocardial infarction with 80 percent mid LAD lesion , now status post angioplasty . Hypertension . Chronic renal insufficiency . Chronic obstructive pulmonary disease . Guaiac positive stools . Anemia . DISCHARGE MEDICATIONS : 1. Lipitor 10 mg q.d. 2. Lisinopril 2.5 mg q.d. 3. Flovent 110 micrograms aerosol two puffs b.i.d. 4. Aspirin 325 mg q.d. 5. Combivent MDI p.r.n. 6. Toprol XL 100 mg q.d. DISPOSITION : At the time of discharge , the patient 's vital signs were stable and he was without complaints . DISCHARGE STATUS : He will be discharged to home and was cleared by Physical Therapy . FOLLOW UP : He has been scheduled for follow-up with Dr. Martha on 2015-03-25 at 11:00 a.m. It was discussed with him the need to schedule follow-up for colonoscopy with his PCP as well . He will call the Cardiology Division at Addison Gilbert Hospital Greenfield to schedule a follow-up with his cardiologist there within the next week . Lucile Minor Etta , MD 12ADA Dictated By : Emily M. Cassidy , M.D. MEDQUIST36 D : 2015-07-29 17:03:53 T : 2015-07-29 22:08:30 Job #: 81504 Signed electronically by : DR. Brenda JM. Espinosa on : Maxine 2015-09-10 1:57 PM ( End of Report )