DISCHARGE DIAGNOSES:
1.
Non-ST elevation myocardial infarction status post
cardiac catheterization and stenting in the right
coronary artery, left anterior descending, and
diagonal branch.
2.
Anemia, most probably related to gastric and duodenal
ulcers.
3.
B12 deficiency.
PAST
1.
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4.
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12.
MEDICAL HISTORY:
Gastroesophageal reflux disease.
Hypertension.
Seborrheic dermatitis.
Cerebrovascular accident with left hemiparesis.
Right eye blindness secondary to some injury.
Coronary artery disease status post stenting of RCA
and LAD in February 2004.
Abdominal aortic aneurysm.
Iron-deficiency anemia.
Emphysematous cholangitis.
Allergic rhinitis.
Mitral regurgitation.
Congestive heart failure with ejection fraction of
around 40%.
HOSPITAL COURSE: The patient is an 85-year-old male with
the above-mentioned past medical history. He came to
O'Connor ER after an episode of chest pain while he was at
home. His chest pain was relieved with nitroglycerin. In
the ER it was found that he had T wave inversion on his EKG
and CPK and troponin were high. He was admitted to ICU with
a diagnosis of non-ST elevation MI. He was also found to
be anemic and his stool was positive for guaiac. No active
bleeding was noted and the patient refused gastric lavage.
He denied any rectal bleeding or hematemesis. He also
denied any abdominal pain, nausea, vomiting, or diarrhea.
His appetite was normal. He was taking some NSAIDs as
needed for pain as an outpatient.
The patient was admitted to ICU with a diagnosis of non-ST
elevation MI and anemia, most probably related to GI
bleeding. Cardiology consultation was done by Dr. Shahid
Siddiqui and gastroenterology consultation was done by
Dr. Huy Trinh.
The patient went for upper endoscopy, which showed healed
gastric and duodenal ulcers. No active bleeding was noted.
The patient was transfused with packed red blood cells and
he was also on Protonix 40 mg IV twice a day. Later on the
patient went for cardiac catheterization and had stenting
done in the right coronary artery, LAD, and diagonal
branch. The patient tolerated the procedure very well.
During this hospitalization, he denied any chest pain,
shortness of breath, or palpitations. He is on Plavix now
along with lisinopril, Coreg, and Imdur. He is also on
Protonix and ferrous sulfate. He is tolerating his diet
very well. No rectal bleeding or melena was noted. He
also received physical therapy during this admission along
with social worker evaluation.
The patient has some B12 deficiency and he is being given
1000 mcg of B12 IM. Anemia will be repeated as an
outpatient and he will be given B12 as needed as an
outpatient.
A CT of the abdomen was done at the time of admission
because he has a history of abdominal aortic aneurysm and
his blood pressure was on the lower side at the time of
admission. The CT did not show any bleeding from the
aneurysm. The CT of the abdomen also showed a less than
5-mm non-calcified extrapleural nodule, which is
nonspecific. The CT of the chest will be repeated as an
outpatient for followup. The patient is refusing any
further workup for this nodule at this time. The risks and
benefits were explained to him in detail.
The patient lives by himself and he has some help at home.
He lives in some kind of assisted facility. Social worker
evaluation was also done during this admission. The
patient is refusing to go to any skilled nursing facility.
The risks and benefits were explained to him in detail but
he wants to go home. Fall precautions were advised to him
in detail. He uses walker for ambulation. Home RN
evaluation and home PT is also ordered. The patient's
hematocrit at the time of discharge is 10.1 with hemoglobin
of 28.9. The patient is refusing to stay for one more day
in the hospital. He is waiting to receive one unit of
packed cells before discharge and so the patient will be
transferred with one unit of packed red blood cells before
he goes home today. As mentioned, there is no active
bleeding including rectal bleeding or melena was noted and
he is tolerating his diet very well without any symptoms.
PHYSICAL EXAMINATION:
GENERAL: The patient is sitting up in bed, not in
distress; very cooperative and pleasant.
Blood pressure is 120/62, pulse is 70, respiratory rate is
20, temperature is 97.5, 02 saturation is 95% on room air.
Pain assessment 0/10.
CHEST: There is normal vesicular breathing without any
added sound including rhonchi or crepitations.
HEART: S1, S2 regular. The patient has an ejection
systolic murmur at the aortic area and pan-systolic murmur
at the mitral area.
ABDOMEN: Soft without any tenderness. Liver, spleen and
kidneys are not palpated. Bowel sounds are positive and
normoactive. Percussion was tympanic throughout.
EXTREMITIES: There is no pedal edema or calf tenderness
noted. Bilateral femoral pulses are normal. Pedal pulses
are feeble but bilaterally symmetrical. No sign of
ischemia or cyanosis noted. Extremities are warm.
CNS: The patient is alert, awake, and oriented to time,
place and person. He has left hemiparesis.
INVESTIGATIONS: WBC count is 4.8, hemoglobin 10.1,
hematocrit 28.9, platelets 138,000, MCV 92, MCH 32. Sodium
136, potassium 3.9, chloride 105, bicarb 25, glucose 91,
BUN 17, creatinine 1.2, calcium 8.4. Reticulocyte count
3.8%, INR 1.2, PTT 26. Albumin 3.4. CPK went down from
255 to 50. A repeat troponin went down from 1.2 to 0.9.
AST 69, alkaline phosphatase 62, LDH 576, BNP 582, ALT 27,
CK-MB 27.8 and went down to 4.6. Transferrin saturation
28.8%, B12 294. Folic acid 8.1.
Echocardiogram showed inferolateral hypokinesia with mitral
dyskinesia with ejection fraction of 40%. Severe
directional mitral regurgitation and mild aortic
regurgitation.
EKG showed normal sinus rhythm with left atrial
abnormality, first-degree AV block, left anterior
fascicular block, and nonspecific ST changes in V4 to V6
with T wave inversions in V4 to V6.
A CT of the abdomen and pelvis showed abdominal aneurysm
with a diameter of 4.6 in the lateral and 4.4 in the AP
diameter. No CT evidence of acute or subacute rupture or
leakage of this aneurysm. There is aneurysmal dilatation
on both common iliac arteries, right greater than left.
Also showed a small, less than 5-mm non-intensified
extrapleural nodule in the right lung base, which looks
nonspecific. There is some air in the biliary tree.
Chest x-ray showed borderline cardiomegaly without any
cardiopulmonary disease.
Upper endoscopy showed gastric and duodenal ulcers with any
active bleeding.
CONDITION ON DISCHARGE: The patient is feeling much
better. He denied any chest pain, shortness of breath, or
palpitation during this admission. No rectal bleeding or
melena was noted. He is tolerating his diet very well. He
is ambulatory with the help of a walker. He denied any
cough. No fever.
ACTIVITY: As tolerated with the help of walker.
patient was advised about fall precautions.
DIET:
The
2-gram sodium, low-cholesterol diet.
DISCHARGE MEDICATIONS:
1.
Lisinopril 5 mg p.o. once a day.
2.
Coreg 6.25 mg p.o. twice a day.
3.
Plavix 75 mg p.o. once a day.
4.
Nexium 40 mg p.o. once a day.
5.
Imdur 30 mg p.o. once a day.
6.
Multivitamin 1 tablet p.o. once a day.
7.
Zocor 40 mg once a day.
8.
Zetia 10 mg once a day.
9.
Ferrous sulfate 325 mg p.o. once a day.
10. The patient advised to continue Flonase and Claritin.
11. Nitroglycerin 0.4 mg sublingual p.r.n. for chest pain.
FOLLOWUP CARE: The patient is being discharged home to
home as per his request. He is refusing to be transferred
to a SNF and does not want to stay in the hospital for one
more day. The risks and benefits were explained to him in
detail. Fall precautions were advised to him in detail.
Home RN evaluation and home PT has been ordered. The
patient is advised to report to ER or call 911 if there is
any recurrence of symptoms. He is also advised to see me
in about three weeks, as I will be out of town, and also
advised to see Dr. Aravamuthan, who will be covering for me
in the meantime if needed. The patient is also advised to
see Dr. Siddiqui in about one week and have a CBC done in
five days to be followed by Dr. Siddiqui to check on the
level of hemoglobin and hematocrit.
The patient is agreeing with the followup care and the
discharge planning.
A CT of the abdomen and chest will also be repeated as an
outpatient to follow up for aneurysm and also the small
lung nodule. The patient has refused any further workup of
the small lung nodule at this time. The risks and benefits
were explained. The patient is also advised not to take
aspirin or any NSAID.
The patient's condition was discussed with Dr. Siddiqui and
according to his recommendation the patient is stable to go
home and he would like to see the patient in about one
week.