DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old patient who presented to the emergency room after awakening in the middle of the night with chest pain. The patient described the chest pain as feeling like someone was sitting on her chest. At the nursing home, she was given Maalox, which did not relieve the discomfort. Sublingual nitroglycerin was given, which gave her some relief. In the emergency room, additional nitrates were given, and the patient became pain-free. The patient denied any shortness of breath, radiation of the pain, nausea, vomiting, diaphoresis, fever or cough.
PAST MEDICAL HISTORY: Positive for hypertension as well as non-insulin-dependent diabetes mellitus. She is status post mastectomy in the remote past for breast cancer. She is also status post myomectomy for fibroids at age (XX), status post MI, status post fractured hip with a subsequent hip replacement, status post recent hospitalization for hypoglycemia, and status post recent hospitalization for fractured pelvis. The patient had been bedbound at the nursing home as a result of the fractured pelvis.
MEDICATIONS: Prandin 2 mg p.o. t.i.d. q.p.c., calcitriol 0.125 p.o. daily, folic acid 1 mg two tablets p.o. daily, Cozaar 50 mg one tablet p.o. daily, Norvasc 5 mg one tablet p.o. daily, and Toprol-XL 50 mg one tablet p.o. daily.
ALLERGIES: There are no known drug allergies.
SOCIAL HISTORY: Negative for cigarette smoking, alcohol or drug abuse.
FAMILY HISTORY: Pertinent for a sister who developed colon cancer in her early 70s.
REVIEW OF SYSTEMS: The patient has a history of subclinical hyperthyroidism, which gives her a tremor. The patient has refused treatment for this condition. The patient also has known moderate mitral regurgitation and tricuspid regurgitation as well as aortic insufficiency. She has had history of episodes of pulmonary edema. The patient has a history of normocytic anemia, which is an anemia of chronic disease, apparently secondary to her renal disease. There was a history of hyperlipidemia as well as elevated homocysteine levels.
PHYSICAL EXAMINATION: VITAL SIGNS: On admission, temperature 97.6, pulse 74, respirations 18, blood pressure 158/50, and O2 saturation 92% on room air. HEENT: Pupils are equal, round, and reactive to light. Pharynx clear. Poor dentition. NECK: No cervical adenopathy. No JVD. No carotid bruits. HEART: Regular rate and rhythm. Positive systolic murmur at the right second intercostal space. LUNGS: Bilateral rhonchi and bibasilar rales. ABDOMEN: Normoactive bowel sounds, soft, nondistended, and nontender. No masses palpated. EXTREMITIES: No cyanosis, clubbing or edema. NEUROLOGIC: The patient is alert and oriented x3. Cranial nerves II through XII are intact. There are no focal neurological deficits. The patient is able to stand but requires assistance with walking with a walker and is subsequently bedbound for much of the time.
EKG shows normal sinus rhythm with nonspecific intraventricular conduction delay. There is T-wave inversion in leads I and aVL as well as ST segment depression in leads V4 to V6. Portable chest x-ray, hazy opacities both lung bases.
LABORATORY DATA: On admission, pertinent for CBC showing a hemoglobin of 8.2 and hematocrit 24.2 with an MCV of 95.8. The differential included 76% polys and a total white blood cell count of 9200. SMA-7 showed sodium 141, potassium 6.1, chloride 106, bicarbonate 22, BUN 48, creatinine 1.9, glucose 146, and calcium 10.6. Initial troponin was positive at 0.436. Urinalysis showed moderate leukocyte esterase with 850 white blood cells per high power field and 5 red blood cells per high power field.
HOSPITAL COURSE: The patient was admitted with chest pain, rule out myocardial infarction. She was admitted to telemetry. Her CPK-MB fractions were negative. The elevated troponin levels were difficult to interpret due to her history of chronic renal failure, which may have contributed to the elevated troponin level. Nitroglycerin paste was applied for control of her hypertension as well as providing preload reduction for her congestive heart failure.
The patient was continued on Prandin for her diabetes and placed on a no-concentrated-sweets diet. Sliding scale regular insulin coverage was also ordered. Her diet also included a restriction of 70 grams protein and 2.5 grams of potassium. Dr. John Doe was called as a cardiology consult. It was recommended that the patient be transfused to a hemoglobin of 10.5. The patient was therefore transfused with 2 units of packed red blood cells. It should be noted that the patient was also made a DNR status on admission. The patient’s nitroglycerin paste was changed by Cardiology to Imdur 60 mg q.a.m. and 30 mg at bedtime.
She continued to do well on this medication and was free of any chest pain. Her hemoglobin came up to a level of 12.6 with a hematocrit of 32.2. The patient was discharged back to the nursing home. It was felt that her chest pain was angina secondary to an episode of CHF. It was also felt that the patient ruled out for an MI. Her diet continued as 2-gram sodium, low-cholesterol, 80-gram protein, 2.5-gram potassium restricted diet with no concentrated sweets.
DISCHARGE MEDICATIONS: Imdur 60 mg p.o. q.a.m. and 30 mg p.o. q.p.m., Prandin 2 mg p.o. t.i.d. q.p.c., calcitriol 0.25 mg p.o. daily, folic acid 1 mg two tablets p.o. daily, Cozaar 50 mg one tablet p.o. daily, Norvasc 5 mg one tablet p.o. daily, Toprol-XL 50 mg one tablet p.o. daily, and Demadex 10 mg p.o. q.a.m., and ferrous sulfate 325 mg p.o. b.i.d.
