DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
PRIMARY CARE PHYSICIAN: John Doe, MD
CHIEF COMPLAINT: The patient presented with a chief complaint of chest pain x1 day.
PRINCIPAL DIAGNOSES:
1. Atypical chest pain.
2. History of atrial septal defect.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic male with a past medical history of congenital heart disease, possible ASD, status post repair when he was (XX) months old. The patient states that he was sitting in his chair when he started having chest pain, which presented as pressure–like, about 5 minutes in duration, nonradiating, and rated as 8/10, constant and multiple episodes x1 day. The patient states that he had a similar episode of this one month ago and was taken to the ER where an echo was done. According to the patient, one side was pumping more than the other, and the patient needs to have surgery for that. The patient denies shortness of breath, palpitations, and any aggravating or alleviating factors. No fever or chills.
PAST SURGICAL HISTORY: The patient has had an appendectomy.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS: He is on no medications at home.
SOCIAL HISTORY: The patient is currently unemployed. He does not smoke or use alcohol. He lives with his mother.
FAMILY HISTORY: The patient states one of his grandfathers had heart problems, and he is not sure of other family medical history.
REVIEW OF SYSTEMS: No fever or chills. No nausea or vomiting. No skin changes. No blurring of vision. Positive chest pain. No palpitations. No orthopnea. No PND. No shortness of breath. No cough. No nausea or vomiting. No urinary problems. No blurring of vision.
PHYSICAL EXAMINATION: GENERAL: The patient is a (XX)-year-old Hispanic male, in no apparent distress. SKIN: No rashes. HEENT: Normocephalic and atraumatic. Pupils are equally round and reactive to light. Throat is moist. No erythema and no exudates. NECK: Supple. No JVD and no bruits. CHEST: Nontender to palpitation. HEART: S1 and S2 present, 2/6 systolic murmur and early diastolic murmur in the left sternal border. LUNGS: Clear to auscultation. ABDOMEN: Soft. Positive epigastric pulsation. Positive bowel sounds. No organomegaly. NEUROLOGIC: The patient was awake, alert, and oriented. Cranial nerves II through XII are intact. No focal deficits.
LABORATORY DATA: Troponins were negative x3. The patient’s sodium was 140, potassium was 4.2, chloride was 104, bicarbonate was 26, BUN was 8, creatinine was 1.2, and glucose 92.
HOSPITAL COURSE: The patient was admitted for chest pain to rule out MI. The patient had lipid profile, cardiac enzymes, and 2D echo ordered. The patient was given sublingual nitroglycerin and morphine for the pain. Chest x-rays were ordered. Aspirin 325 mg was given and Lopressor 12.5 mg was also ordered. The patient had an echo done, which showed right bundle branch block, septal conduction delay, and moderate pulmonic stenosis with pulmonary insufficiency. The patient was ruled out for MI, and the patient was scheduled for cardiac MRI as an outpatient.
DISCHARGE DISPOSITION: The patient was discharged home the day after presenting.
DISCHARGE MEDICATIONS: The patient was discharged on Lopressor 12.5 mg b.i.d. and aspirin 325 mg a day.
FOLLOWUP: Followup appointment was made at cardiology clinic.
DISCHARGE INSTRUCTIONS: The patient was given prescriptions for the cardiac MRI.
The patient had 2D echo Doppler study done, electrocardiogram, chest x-ray, and cardiac enzymes done.
