814743340 RWH
3393103
501370
9041109
5/13/2006 12:00:00 AM
Discharge Summary
Unsigned
DIS
Report Status :
Unsigned
DISCHARGE SUMMARY
NAME :
TRICHEPRAKEJESC , BETLA
UNIT NUMBER :
381-75-78
ADMISSION DATE :
05/13/2006
DISCHARGE DATE :
05/16/2006
PRINCIPAL DIAGNOSIS :
Chest pain .
ASSOCIATED DIAGNOSIS :
Coronary artery disease ; hypertension ; hyperlipidemia ; sleep apnea ; diabetes type 2 .
PROCEDURES :
Adenosine stress test .
Part 1 of a sleep study .
Coronary angiogram .
Chest CT .
Chest x-ray .
HISTORY AND REASON FOR HOSPITALIZATION :
The patient is a 55-year-old gentleman with a history of CAD status post non ST elevation MI in 11/17 who presents with chest pain X 48 hours .
He went to Padrugmoff Hospital Emergency Room .
He has a history of hypertension , diabetes , and high cholesterol .
In 2003 , he had a non ST elevation MI , came to the RWH , and had a cath done , which showed a 40% RCA , which was hazy .
An IVUS was done , and it was felt that it was more severe .
He underwent a PTC stenting of an RCA with a Vision stent , 3 x 18 .
Diagonal 1 also had a 99% stenosis .
There was no other noted disease .
Since then , the patient has occasional chest pain with emotional stress , when he is angry or upset .
Yesterday morning , he developed intermittent substernal chest pain with radiation to the left shoulder that worsened with any activity and any motion of his shoulders .
It progressed over the course of the day requiring less movement .
He also became short of breath with climbing a flight of stairs .
He denies diaphoresis or nausea .
He went to the Padrugmoff Hospital Emergency Room after trying nitroglycerin at home .
However , his nitroglycerin was old and the script was expired .
In the ER , he received 3 sublingual nitroglycerins and 1 mg of Dilaudid .
After that , he was pain-free .
Lopressor IV was given to control his heart rate .
He also received Lipitor 80 mg , Plavix 300 , heparin IV , integrelin double bolus , followed by a drip .
Apparently once his pain was free , his EKG was noted to have hyperacute T-wave anteriorly without progression .
He was transferred to the Ro Woodma Healthcare for further cardiac care .
PAST MEDICAL HISTORY :
Diabetes ; hypertension ; hyperlipidemia .
MEDICATIONS AT HOME :
Include Lisinopril 5 mg p.o. every day ; nitroglycerin sublingual p.r.n.; Toprol XL 100 mg p.o. every day ; Plavix 75 mg p.o. every day ; Avandia 4 mg p.o. every day ; Lipitor 40 mg p.o. every day ; TriCor 145 mg p.o. every day .
SOCIAL HISTORY :
He is married .
He does have a lot of anxiety .
Socially he drinks alcohol .
He does not smoke .
He has 2 daughters .
HOSPITAL COURSE :
The patient ruled out for an MI with negative CK X4 and negative troponin X4 .
He was taken to the Cardiac Catheterization Lab where cath showed top-normal LVEDP at 12 ; no AF ; widely patent RCA stent ; mild CAD in the left coronary artery symptom ; widely patent diagonal 1 at the site of prior PTCA .
He received an Angio-Seal to the right common femoral artery .
He then underwent a CT scan to rule out a PE .
That test was negative .
He underwent lower extremity study to rule out a DVT in both legs .
That was negative .
He was noted to have an episode of desaturation into the 80% range while sleeping .
Pulmonary consult was done , and it was felt that the patient should undergo a formal sleep study , full PFTs , and a repeat CT scan in 1 year to assess for pulmonary nodule that was seen .
However , please note that this nodule has been stable over time .
The patient also complained of intermittent right neck swelling , and recommendations are to consider a CT scan with contrast to evaluate nodes in his neck .
On physical exam today , the patient did not have any swelling , and he states that he did not feel the swelling was present .
The patient underwent an adenosine stress test , where he exercised for 4 minutes , reaching 65% of predicted heart rate .
He did not have chest pain .
EKG was negative for ischemia .
The myocardial perfusion images show no definite evidence of ischemia .
The LV contractile function was normal .
There was mild posterior vasal thinning .
It is not clearly outside normal limits .
He underwent an echocardiogram , which showed an EF of 60% .
There was no evidence of MVP .
There was trace mitral regurgitation .
There was no evidence of LA dilatation .
There was no aortic stenosis .
There was trace aortic insufficiency .
The LV cavity size was normal .
The systolic function was within normal limits .
There was no evidence of LV hypertrophy .
There was no obvious segmental wall-motion abnormality .
There was no evidence of pericardial effusion .
The right ventricle was not dilated .
The systolic function was within normal limits .
The patient underwent a sleep study , the first part , which showed that he had 75 respiratory events observed with apnea , hypopnea index of 11 an hour .
The mean heart rate was 68 .
They felt that there was obstruction and possible obstruction to airflow generating some obstructive apnea , as well as partial obstructive events .
They recommended that the patient may benefit from a trial of continuous positive pressure at the bedside .
The patient has been scheduled to have the second part of the sleep study done on June 18 , 2006 , at 8:30 p.m. at RWH in the Esley Community Hospital , 10th floor sleep lab , phone number 133-225-1257 .
Prior to discharge today , he underwent PFTs .
The results of the PFTs are unavailable at the time of this dictation .
Based on all the tests above , it was felt that the patient was stable for discharge home .
His blood pressure was 114 to 123/62 .
Heart rate 69 to 80 .
Room air saturation 96% .
Temperature 97.9 .
Lung sounds clear bilaterally .
Heart sounds :
Regular rate and rhythm ; S1-S2 ; positive S4 ; no murmur .
Abdomen :
Soft , nontender , nondistended ; no guarding ; no masses ; positive bowel sounds X4 .
Right groin status post catheterization showed no hematoma or bruit .
Lower extremity pulses were intact without any edema .
Lab values :
Sodium 139 ; potassium 4.1 ; BUN 15 ; creatinine 1.1 ; magnesium 1.6 ; SGPT 19 ; SGOT 20 ; alkaline phosphatase 66 ; total bilirubin 0.6 ; direct bilirubin 0.2 ; total cholesterol 234 ; triglycerides 274 ; HDL 44 ; LDL 135 ; hemoglobin A1c 6.7 ; white cell count 6.1 ; hematocrit 36.4 ; platelet count 201 .
During the hospital course , the patient was started on a PPI , Nexium , for concerns of acid reflux .
Also , a long discussion was taken with the patient as most of his chest discomfort happens when he is quite anxious .
He used Ativan in the hospital , which helped him .
The patient was advised that he needs to speak with his PCP about medication for antianxiety and / or further testing or counseling to help control his anxiety level .
MEDICATIONS ON DISCHARGE :
Nitroglycerin 1 tablet sublingual q. 5 minutes X3 p.r.n. chest pain .
TriCor 145 mg p.o. every day .
Lipitor 40 mg p.o. every day .
Plavix 75 mg p.o. every day .
Aspirin 325 mg p.o. every day .
Lisinopril 5 mg p.o. every day .
Avandia 4 mg p.o. every day .
Toprol XL 100 mg p.o. every day .
Prilosec 20 mg p.o. every day .
Ativan 0.5 mg p.o. b.i.d. p.r.n. anxiety .
The patient was asked to follow up with his PCP , Dr. Cora Belbsnil , at Necrestneysagiles Medical Center in a period of 1 to 2 weeks .
He was asked to follow up with Dr. Riale Tables , his cardiologist , in a period of 1 to 2 weeks ; he also works at Necrestneysagiles Medical Center .
The patient was told that he should discus with his PCP further GI testing , as well as medications for anxiety .
The patient will need to have a followup sleep study done as above per the recommendations based on the results .
CONDITION ON DISCHARGE :
Stable .
RYROL DALEDAE , NP
DICTATING FOR :
Unreviewed
_____________________________ NAA NARICHA EARLY , M.D.
TR :
so
DD :
05/16/2006
TD :
05/17/2006 7:29 A 501370
cc :
NAA NARICHA EARLY , M.D.