DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
DISCHARGE DIAGNOSIS: Non-ST elevation myocardial infarction.
PRIMARY CARE PHYSICIAN: John Doe, MD
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg daily.
2. Plavix 75 mg daily.
3. Lopressor 50 mg twice daily.
4. Lipitor 80 mg daily.
5. Wellbutrin SR 150 mg as previously directed.
PROCEDURE: Cardiac catheterization with angioplasty and stent placement to the LAD and RCA.
COMPLICATIONS: None.
HISTORY OF PRESENT ILLNESS: This (XX)-year-old male with no previous history of heart disease presented complaining of a 4-day history of waxing and waning chest pain radiating to the left arm. He was admitted to the hospital. Peak troponin was 1.5, peak CPK 420, MB 6.2 and index 1.5%. The patient then underwent cardiac catheterization, which revealed a 90% proximal LAD lesion, a 60% lesion of the first obtuse marginal and a 90% mid RCA lesion with a normal ejection fraction. He was then transferred here for intervention.
PAST MEDICAL HISTORY: Hypertension.
MEDICATIONS PRIOR TO ADMISSION: None. The patient had stopped taking his antihypertensive medications.
FAMILY HISTORY: Positive for coronary artery disease. Mother had an MI at the age of 65 and father died of sudden cardiac death at the age of 70.
SOCIAL HISTORY: Current smoker, greater than 25 years. Rarely drinks alcohol.
ALLERGIES: None known.
PHYSICAL EXAMINATION:
GENERAL: The patient is a well-developed, well-nourished male, in no acute distress. Alert and oriented x3. Smiling and conversant.
HEENT: Normocephalic and atraumatic.
NECK: No lymphadenopathy, JVD, thyromegaly or carotid bruits.
LUNGS: Clear.
HEART: Regular rate and rhythm without murmurs, rubs or gallops.
ABDOMEN: Soft and nontender. Right groin side is soft without hematoma or bruit.
EXTREMITIES: Warm, dry and intact without clubbing, cyanosis or edema, +2 peripheral pulses. Ambulates with steady gait without difficulty.
LABORATORY DATA: On the day of discharge, white blood cell count 8700, hemoglobin 14.2, hematocrit 41.8, platelet count 280,000. Sodium 141, potassium 3.9, chloride 107, CO2 of 26, BUN 10, creatinine 1.1, glucose 90. CPK 165, MB 4.2 and troponin 1.66.
HOSPITAL COURSE: This is a (XX)-year-old male who was transferred here to the cardiac catheterization laboratory, where he underwent cardiac catheterization. The 90% proximal LAD lesion was treated with a Cypher 3.5 x 13 mm drug-eluting stent. The 99% mid right coronary artery lesion was treated with a 3.0 x 18 mm Cypher drug-eluting stent. The femoral arterial sheath was removed with manual compression without incident. The patient was admitted to the telemetry unit postprocedure for overnight observation. On the evening postprocedure, he had one episode of paroxysmal atrial fibrillation, approximately 30 seconds at a rate of 140. Blood pressure was stable at 132/74. The patient was asymptomatic during this brief episode, which was self-limiting. He had no symptoms whatsoever. He then remained in stable condition overnight with no further episodes of ectopy nor any symptoms of angina. In the morning, he was seen in consultation by Physical Therapy and Nutrition, and he was felt to be stable for discharge to home for outpatient followup.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient is discharged home for outpatient followup with Dr. Jane Doe in 1 to 2 weeks. He will also follow up with his primary care physician, Dr. John Doe, within 4 to 6 weeks. The patient has been advised the importance of smoking cessation. He does plan to quit. He has been given a copy of the discharge plan with instructions, medications and prescriptions and will talk to Dr. Jane Doe at the time of his followup visit regarding indication for cardiac rehab and if he has any further questions or concerns.
