Age: 65.0
Sex: F
Vaccine: COVID19-2
Symptoms: Cardiac murmur, Catheterisation cardiac abnormal, Chest discomfort, Chest pain, Chronic obstructive pulmonary disease
Clinical narrative: Date of Admission Admit Date: Jan-12-2023  Date of Discharge Date of discharge Jan-13-2023 @ 1000  Allergies Doxycycline - Not Specified  plastic - Not Specified  Amitriptyline - Not Specified  Tetracyclines & Related - Not Specified  Penicillins - Not Specified  Macrodantin - Not Specified  Erythromycin - Not Specified  Chief Complaint Chest pain  Final Diagnoses Acute ST segment elevation myocardial infarction  Coronary arteriosclerosis  Dissection of coronary artery  Chronic obstructive lung disease  Tobacco dependence syndrome  Acute pericarditis  Lab Results Jan-13-2023 0632 Chemistry GLUCOSE  85BUN  9CREAT  0.8MDRD GFR  72NA  141K  4.1CL  105CALCIUM  8.3CO2  31.6OSMO  279.2ANION GP  8.5BUN/CRE  11.3 Jan-13-2023 0632 Hematology WBC  10.5RBC  3.96HGB  11.9HCT  36.9MCV  93.2MCH  30.1MCHC  32.2RDW  16.6PLT  220MPV  10.5NRBC%  0.0 Jan-12-2023 2201 Serology COVID  PosCVD1TEST  NCVDEMPHC  NCVDSYMP  NCVDSYMDT  NCVDHOSP  NCVDICU  NCVDRESID  NCVDPREG  N Jan-12-2023 1155 Chemistry ACT  190 Jan-12-2023 1100 Chemistry ACT  260 Jan-12-2023 1038 Chemistry ACT  190 Jan-12-2023 0957 Chemistry GLUCOSE  92BUN  11CREAT  0.9MDRD GFR  63NA  143K  3.6CL  105CALCIUM  9.0ALK PHOS  81CO2  33.1AST  14ALT  26AST/ALT  0.5TL PROT  6.3ALBUMIN  3.6TBILI  0.6OSMO  284.0ANION GP  8.5BUN/CRE  12.2TSH  1.38MAGNESIU  2.3TROPI-HS  13 Jan-12-2023 0957 Hematology WBC  14.8RBC  4.31HGB  12.9HCT  40.0MCV  92.8MCH  29.9MCHC  32.3RDW  16.7RDWSD  56.8PLT  261MPV  10.4AUTONEU%  63.9AUTOLYM%  26.6AUTOMON%  8.6AUTOEOS%  0.5AUTOBAS%  0.1AUTONEU#  9.5AUTOLYM#  3.9AUTOMON#  1.3AUTOBAS#  0.0AUTOEOS#  0.1NRBC%  0.0NRBC  0.0HGB/HCT  3.1IG#  0.05IG%  0.3 Imaging Results cardiac catheterization demonstrated nonocclusive disease in the LAD and left circumflex artery the mid right coronary artery had what appeared to be a dissection this underwent stenting.  I also felt that her LV g demonstrated some mild inferior wall hypokinesis but an overall EF of 50 the 55%  Functional Status* No Functional Impairments  Mental Status* Normal Cognition  Social History tobacco use Current Every Day Smoker, Smoking Cessation Yes  marital status Married  Health Concerns Dissection of coronary artery  Chronic obstructive lung disease  Tobacco dependence syndrome  Stented coronary artery  Coronary arteriosclerosis  Acute ST segment elevation myocardial infarction  Current Every Day Smoker  Father Deceased  Mother Deceased  Tobacco Cessation* FDA Tobacco Cessation Medication has been prescribed (see discharge medications) ( Nicoderm or neck it read over-the-counter)  Vital Signs Jan-13-2023 0645 T 98.2 HR     59 RR 18 BP   126 / 63 O2Sat 96 Jan-13-2023 0310 T 98.0 HR 61 RR 16 BP   108 /     50  O2Sat 93 Physical Exam General Normal appearance, Awake, Alert  HEENT Head Normocephalic  Eyes Negative For: Conjunctival discharge, Conjunctival Erythema, Conjunctival hemorrhage, Corneal abrasion, Corneal foreign body, Corneal laceration, Scleral icterus, Red reflex, Retinal detachment, Retinal Hemorrhages  Ears Negative For: Foreign body in ear, Tenderness, Cerumen, Bloody discharge, External drainage, Edema  Nose Negative For: Nasal mucosa boggy, Swelling, Inflammation, Epistaxis, External drainage, Deviated nasal septum  Sinus Negative For: Swelling over maxillary sinus, Swelling over frontal sinus, Maxillary sinus Tenderness, Frontal sinus tenderness  Mouth and Throat Negative For: Erythema of throat, Exudate, Tonsillar enlargement, Posterior rhinorrhea, Dysphagia, Ulcer, Multiple plaques, Dental caries, Halitosis, Gingival Hyperplasia, Gingivitis  Neck Negative For: Jugular Venous Distention, Bruit, Tenderness, Lymphadenopathy, Goiter, Thyroid nodule, Mass, Reduced Range of Motion, Swelling, Nuchal rigidity  Respiratory Positive For: Rales.  Cardiovascular Heart Rhythm Regular, Regular Rate  Positive For: Systolic murmur.  Peripheral Vascular/Extremities Negative For: Cold extremities, Peripheral cyanosis, Edema, Venous ulcer of leg, Red extremities, Shiny skin, Homans' sign, Edema of lower extremity, Gangrene, Discoloration of skin, Traumatic injury  Breasts Negative For: Tenderness, Swelling, Nipple discharge, Retraction of nipple, Orange peel surface of breast, Breast lump, Dimpling of surface of breast, Gynecomastia, Breast implant(s)  Abdomen Negative For: Abdominal tenderness, Rebound Tenderness, Guarding, Enlargement/Organmegaly, Distention, Right flank pain, Left flank pain, Hypoactive bowel sounds, Hyperactive bowel sounds, Generalized abdominal dullness to percussion, Abdomen hyper-resonant, Obturator sign, Obese, Murphy sign, Iliopsoas muscle test, Hernia, Bruit, Abdominal mass  Musculoskeletal Negative For: Traumatic injury, Joint swelling, Clubbing  Skin/Integumentary Skin Appearance Negative For: Nonpitting edema, Pitting edema, Dehydrated, Diaphoresis, Telangiectasis  Neurological Normal neurological function, Normal cranial nerves 2-12  Psychiatric Negative For: Paranoid, Hallucinations, Delusions, Labile affect, Mood swings, Inappropriate behavior, Inappropriate affect, Hypomanic behavior, Euphoria, Depressive disorder, Apathetic, Agitated, Anxiety, Angry  Hospital Course patient came to the hospital with an hour of her chest pain she was taken to the cath lab where his found that her mid right coronary artery had perhaps some while dissection with thrombus this was stented and she got heparin Aggrastat and Brilinta during the procedure she did well postop set some still some mild chest discomfort I gave her some colchicine for which seemed to resolve it. we found out afterwards that she would was COVID positive however she has had no symptoms and has been oxygenating well she did want quit smoking but did not want to take Chantix I have instructed her to try the nicorette gum ordered Nicoderm patches which now he can actually get over-the-counter.  She was doing fine the following morning when go home  Condition at Discharge Stable  Discharge Medications Albuterol neb QID Continue taking same as home ASPIRIN LOW DOSE 81 MG CHEWED EVERY 24 HOURS (ePrescribed on Jan-13-2023 0846) ATORVASTATIN CALCIUM 80 MG ORALLY EVERY 24 HOURS (ePrescribed on Jan-13-2023 0846) COLCHICINE 0.6 MG ORALLY TWICE DAILY (ePrescribed on Jan-13-2023 0846) GABApentin 200 MG ORALLY DAILY AT BEDTIME (ePrescribed by on Jan-13-2023 0846) Gabapentin Oral Capsule 100 MG 200 MG ORALLY 3 TIMES A DAY Gabapentin Oral Capsule 300 MG 300 MG ORALLY DAILY AT BEDTIME ipratropium bromide 0.5mg BID Continue taking same as home Lamictal 200 mg tab 200 MG ORALLY TWICE DAILY metoprolol tartrate 25 mg tab Continue taking same as home omeprazole 40 mg cpDR Continue taking same as home sucralfate 1 gram tab Continue taking same as home symbicort 1 puff BID Continue taking same as home TICAGRELOR 90 MG ORALLY EVERY 12 HOURS (ePrescribed by on Jan-13-2023 0846) TIOTROPIUM BROMIDE 2.5 MCG/ACT 2 PUF INHALATION DAILY PER RT (ePrescribed by on Jan-13-2023 0846) tylenol #3 300-30mg 1 tab q4-6h prn Continue taking same as home Discharge Disposition Discharge to home  Plan Will make sure she has a Brilinta or Plavix and him before discharge she will follow-up with me in a month she is to notify us immediately if she has any respiratory symptoms and case she needs something further for the COVID and check with her work to see if she needs to be quarantine for 5 days or more. I will have her see primary care in a week  Primary Care Provider DO  Time Spent with Patient Total number of minutes spent with patient (42), More than 50% of the time spent with this patient was devoted to counseling and coordination of care  discussed with patient and he she voiced understanding  Electronically signed on Jan-13-2023 0907