DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
REASON FOR ADMISSION: The patient is a (XX)-year-old male with a history of GI bleeding in the past and also coronary artery disease with coronary artery bypass grafting, hypertension, subendocardial non-Q-wave myocardial infarction, requiring PTCA and stenting of one of the vein grafts, congestive heart failure, atrial fibrillation, and stroke. The patient presents on the day of admission with a four-day history of shortness of breath with minimal activity. The patient denied orthopnea, PND, chest pain, nausea, vomiting, or diaphoresis. He reports improvement after diuresis received in the emergency department. He also denies fever, chills, or productive cough.
PHYSICAL EXAMINATION:
VITAL SIGNS: On physical examination, blood pressure was 154/78, pulse 72.
HEENT: Normocephalic and atraumatic. EOMI.
NECK: Supple with no JVD. Carotids are 2+. There are no bruits present.
HEART: Irregular rate and irregular rhythm. Normal S1, S2. There is systolic ejection murmur at the left sternal border.
CHEST: Decreased breath sounds in the bases with some crackles.
ABDOMEN: Soft with bowel sounds present. Nontender.
EXTREMITIES: Without clubbing, cyanosis, or edema.
LABORATORY DATA: Digoxin level 0.88, BNP 540, troponin I 2.3, CPK 54, MB 4.3. Sodium 136, potassium 4.3, chloride 106, CO2 of 19, BUN 45, creatinine 3.1, glucose 114. AST is 19 with ALT 20, and total bilirubin of 1.1. WBC 8.6, hemoglobin 10.4, hematocrit 31.2, and platelets 196, 000.
EKG: Atrial fibrillation with PVCs and ST-T wave abnormalities. Chest x-ray: Bibasilar infiltrate/effusions. Worsening CHF.
IMPRESSION:
1. Small non-Q-wave myocardial infarction.
2. Severe renal insufficiency.
3. Coronary artery disease.
4. Congestive heart failure, which is improved with diuresis.
5. Chronic atrial fibrillation, for which he is a poor anticoagulation candidate.
PLAN: The patient will be admitted to hospital and will have his cardiac enzyme cycles and have his medication therapy maximized.
HOSPITAL COURSE: The patient was also seen by Dr. John Doe and also GI service for his anemia. His Lasix doses were adjusted for management of his congestive heart failure. Repeat labs were obtained by GI service, and his anemia remained stable. The patient felt well and was anxious to go home, and therefore, he was discharged later that day. His creatinine was 3.2 with hemoglobin 11.2, and potassium was 3.5 at the time of discharge. The patient was discharged to follow up as an outpatient with his primary care physician.
DISCHARGE DIAGNOSES:
1. Small non-Q-wave myocardial infarction.
2. Congestive heart failure.
3. Renal insufficiency.
4. Coronary artery disease.
5. Chronic atrial fibrillation.
6. History of stroke.
7. History of anemia.
DISCHARGE INSTRUCTIONS:
DIET:
Low fat, low salt.
ACTIVITY:
As tolerated.
MEDICATIONS: Protonix 40 mg p.o. every day, Demadex 80 mg p.o. b.i.d., Norvasc 5 mg p.o. every day, aspirin 81 mg p.o. every day, clonidine TTS one patch weekly, digoxin 0.125 mg every other day, Mevacor 20 mg p.o. every day, Toprol XL 100 mg everyday, and Nitrostat 0.4 mg p.r.n. chest pain.
FOLLOWUP: The patient is to have an SMA-8 drawn at the first visit in two weeks. He is to weigh daily and call us if his weight is up more than 2 pounds in 24 or 48 hours. He is also to call for chest pain or worsening shortness of breath.
