143748600 SC
43243309
095342
09/30/2000 12:00:00 AM
atypical chest pain
DIS
Admission Date :
09/30/2000
Report Status :
Discharge Date :
10/01/2000
****** DISCHARGE ORDERS ******
FALC , COLL 891-57-52-0 T37
Room :
53X-785
Service :
CAR
DISCHARGE PATIENT ON :
10/01/00 AT 03:30 PM
CONTINGENT UPON
ETT
WILL D / C ORDER BE USED AS THE D / C SUMMARY :
YES
Attending :
KOTEZUSTLEEB , LIJO LIFLE , M.D.
CODE STATUS :
Full code
DISPOSITION :
Home
DISCHARGE MEDICATIONS :
ALBUTEROL INHALER 2 PUFF INH QID
Instructions :
PLEASE USE WITH SPACER ( PLEASE INSTRUCT PATIENT ) ECASA ( ASPIRIN ENTERIC COATED ) 325 MG PO QD WELLBUTRIN ( BUPROPION HCL ) 150 MG PO BID GEMFIBROZIL 600 MG PO BID ZESTRIL ( LISINOPRIL ) 20 MG PO QD ZANTAC ( RANITIDINE HCL ) 150 MG PO BID SERZONE ( NEFAZODONE ) 300 MG PO QHS ZYPREXA ( OLANZAPINE ) 5 MG PO QHS
Number of Doses Required ( approximate ) :
4
GLUCOPHAGE ( METFORMIN ) 850 MG PO TID Starting ON 10/03/00 ( 10/03 ) ACTOS 30 MG PO QD
DIET :
House / ADA 2100 cals / dy
RETURN TO WORK :
Immediately
FOLLOW UP APPOINTMENT ( S ) :
Dr. Rotrysbreunkorc 1-2 weeks ,
ALLERGY :
Penicillins
ADMIT DIAGNOSIS :
atypical cp
PRINCIPAL DISCHARGE DIAGNOSIS ; Responsible After Study for Causing Admission ) atypical chest pain
OTHER DIAGNOSIS ; Conditions , Infections , Complications , affecting Treatment / Stay dm ( diabetes mellitus ) anxiety ( anxiety ) htn ( hypertension ) gerd ( esophageal reflux )
OPERATIONS AND PROCEDURES :
OTHER TREATMENTS / PROCEDURES ( NOT IN O.R. )
BRIEF RESUME OF HOSPITAL COURSE :
41 yo man with CRFs of DM Type II , high cholesterol , smoking history , family hx , HTN p / w episodes of atypical CP x 1 week , with rest and exertion .
also has h / o anxiety and GERD .
No assoicated Sx .
Here , had T wave flattening laterally and inferiorly with pain that resolved pain free , but not clear that lead placement is the same .
Had Chest CT to r / o dissection ( due to back pain ) which was neg.
Ruled out for MI .
Will plan on ETT .
Holding Metformin until Friday due to CT with contrast .
ADDITIONAL COMMENTS :
smoking cessation group will contact you at home
DISCHARGE CONDITION :
Stable
TO DO / PLAN :
you will be contacted at home by the smoking cessation program
No dictated summary
ENTERED BY :
WIERST , STO L. , M.D. ( RR86 ) 10/01/00 02:33 PM
****** END OF DISCHARGE ORDERS ******