Discharge Summary

REASON FOR ADMISS ION: ST elevation myocardial infarction.

HISTORY OF PRESEN T ILLN ESS: For co mplete history, kindly refer to thed icat ion dated . Th is patient is an 81-year-oldfemale with a history of hypertension , diabetes type 2, hyperlipidemi a,and coronary artery d isease status post myocardial infarcti on

who presen ted with acute onset of chest pain. The patient wasinitially seen in the_Emergency Department and found to have a STelevation, elevated troponin with a CK-MB percent e levated at 2.3% and wasgiven IV heparin and reteplase 10 units IV push over 2 minutes andtransferred to the or further care.

HOSPITAL COURS E:1. STEM I: Upon arrival, the patient had imm edi ate echocardiograrn doneshowing severe basal inferior hypokinesis and underwent catheterizationhaving 3 drug-eluting stents placed 2 in the proximal and I in the distalRCA- 3 areas of stenosis. The patient was placed on a regim en ofcarved ilol, Plavix,aspirin, lisinopril , and pravastatin . The patient was initi ally admitted to theICU status post catheterization and remained stable. The patient was alsogiven a regimen of n-acetyl- L-cysteine secondary to her recent contrastload and initi al serum creatinine of 1.23. Afte r the patient wastransferred ou t of the ICU, the patient remained stable andhad no event on telemetry for symptomatic events throughout the remainderof her hospi talization .

2. Chronic kidney disease- Stage I : The patient was then in itially adm itted withserum creatinine of 1.23 with an unknown base line. There was some co nce rnthat thi s could have been due to hypertension versus diabetes.After stent placement andn-acetyl-L-cysteine, the pat ient's serum creatinine improved to 0.78.

3. Diabetes mell itus type 2: The patient with a history of chronicdiabetes managed only with diet and exercise. The patient was managed on

Discharge Summary

insulin sliding scale and had no event of hypo or hyperglycemi a throughouther hospitali zation .

4. Hypertension : The patient noted a history of chronic hypertension forwhic h she was taking 10 mg of lisinopril daily, The patient'shypertension rema ined contro lled on carved ilol and lisin opri! throughouther hospitalization with no further events.

5. Prophylaxis: The patient was initi ally managed with heparin therapy onadmiss ion to the le U, which was discontinued after catheterization.

DISCH AR GE DIAGNO SES:1. ST elevation myocardial infarction-RCA2. Chronic kidney disease3. Diabetes type 2.4. Hypertension .5. Coronary artery disease.

DISCH ARGE MEDICATIONS:I . Aspirin 325 mg ora lly daily for I mon th transitioning to aspirin 81 mgora lly daily.

2. Pravastatin 80 mg ora lly daily.3. Plavix 75 mg orally daily.4. N itroglycerin 0.4 rng sublingually as needed for chest pain.5. Carvedilol 3. 125 mg ora lly twice daily. The patient was adv ised tofollow up with her primary care physicians for any symptoms oflighthead edness or d izziness.

6. Lisinopril 5 mg orally once daily.

DISCH AR GE INSTRUCTIONS: The patient was discharged to home in stablecondition. The patient was advised to fo llow up with her primary careprovider, Dr.-,nd with Dr._ in Card iology. Thepatient was advised to continue a low-sodi um, low-fat , low-cholesteroldiet and to absta in from lifting over 20 to 25 pounds for a mi nimum of2weeks. The patient was to follow up with her prim ary care providerregarding lipid panel drawn at the hospital and for furthercholestero l managem ent.

History and Physical

CHIEF COMPLAINT : Chest paln p l u s EKG changes p lus mi ld elevation 1ntroponin .

HI STORY OF PRESENT ILLNESS : Thi s i s a n 81 - yea r -old fema le with ab ackgrou n d h is t ory of hypertens ion , diet -controlled h ype r l i p i demi a ,diet -controlled type 2 diabetes , coronary artery disease , old MIs i nwho pre s en t s with an hour to hour and a hal f episode of chestpa l n .

Thi s all b e gan a t a reception . She r eports wa l king up 30stairs . After climbing t he stai rs , she r eport e d no chest pa i n,pa l p i tat ions , d iaphoresis , o r s hor t ness o f bre ath . Ho we v er, imme diatelya fte r boarding t he bus, s he notic e d a burning / dul l pa in in her lowe ra nterior s t ernum. I t l asted fo r t he duration of t h e half hou r bus ridehome and t he a d d i t i on a l IS -mi nute drive home f rom the bus to her house .She described t his p a i n as diffe rent f rom her p ain before a s her p r e v i o u sMI s; it h a d pre viou s l y t raveled u p into the upper ches t and ne c k. She wasi nst r ucted to go to t he Emergency Depart ment by her son a nd took a bab yaspirin pr i or to h er a r rival i n the ED.

On a r r iva l t o the ED i n , her t e mperature wa s 98.7 , BP 1 5 9 / 6 9, heartrate 72 , Sp0 2 of 92% on r o om a i r , a nd r e spira t o r y ra te 1 5 . CBC wasn ormal . CMP was significant for creat i n i ne of 1 .7, urea ni tro g en 30 , andg lucose 14 9. Troponi n s equa l 0 . 1 . CK was 166 , CK-MB 3 .8 (h i g h ) , CK-MBpercent e qua l 2. 3 %, d -dimer 619 (high) . I t was at this t ime that s her e c eiv e d 4000 unit s o f heparin I V p u sh f ollowe d by an infusion at 1 0 0 0unit s per h our . Th is wa s started at 215 4 hours . Re tep l ase 1 0 u n its I Vpush ove r 2 minutes was started at 2152 hours and 2222 hours . It was a tt his time t h at s he was t r ansfe r red to

History and Physical

PAST MEDICAL HI STORY,1 . Hyperte nsion {on lisinop ril (?) 20 mg ora l l y d a i l y } .2 . Hyperlipidemi a (p r e v i ou s l y on Zo e o r b u t stopped secon dar y t o l e g

p ains ) .3 . Type 2 diabe t e s (d i a g n o s e d 2 y ears ago, n o t c urren t ly on a ny o ral orinjectable medications ) .

4. Coronar y artery dise ase.5 . Old MI6 . (?) DVT .

PAST SURGI CAL HI STORY: Hystere ctomy 4 0 y e a r s ago.

MEDICATI ONS,1. Lisinopril (?) 2 0 mg orally daily.2. Sh e denied t ak ing asplrln, although, it ha s been prescribed (last t a ken

s everal ye a r s a g o ) .3 . Not cur rent l y on stat i n .

ALLERGIES, NO KNOWN DRUG ALLERGI ES .

SOCI AL HI STORY: She denie s s moki n g , drink i ng, or drug use e ve r . She liveswith d a u g h t er .

FAMILY HI STORY: She denies any relevant fami l y h i s tory

PHYS ICAL EXAMINATI ON,

GENERAL,o r i e n t e d

Well- appe a ring f e ma l e, i nx 3, aff e c t appropriate.

no a pparent dist ress , a lert a nd

VI TAL S IGNS : Te mpera t ure3 7 . 1, BP 129 / 4 9 , hear t r at e 7 6 , r e spirato ry rate 25, 98% on 2 li t ers nasalcan nula , a n d BMI of 3 5 . 4 .

HEENT: No sclera l i c t erus. No conj u nc t i va l pallor. No bruits. Notracheal d evia tion. No lymphadenopathy a ppreciated .

CARDIOVASCULAR: Regular r at e a n d rhythm. Heart sounds 1 a nd 2 arepresent. Systol ic ejec t ion murmur, c rescendo - decrescendo h e ard l o u d es t inthe right s e c ond i n t erc os tal s p ace (1 t o 2 out o f 6) . No r adiation to the

History and Physical

c a rot i d s .

RESPI RATORY: Cl ear to ausculta t i on bi l a te r a l ly . No whee zes , no rhonchi ,and no ra l es.

ABDOMEN : Soft and n on t e nder.No ma s s e s . Bowel s ou n ds are

No guarding.p ositive.

No rigidi t y . No o r g a nomeg a ly .

EXTREMI TIES : He moside r i n deposit in the r ight leg. Pedal e dema 2 + .Pe r i p he r a l pulses palpab l e i n l ower l imbs b ila t e r a l ly.

LABORATORY DATA : Lab s : Wh i t e blood ce l l s 7 .64 ,hemoglobin 13 .2 , hematocri t 39 .2 , MeV 94.5 (high), RDW of 15 .7 (high) , andplatelets 153 , 000 (low) .

Cr e atinin e 1.23 (hig h ) , u rea nitrogen 2 8 (h igh) , glucose 144 (h i g h) , AST of5 7 (h i g h) , tot a l pro t e i n 6 .1 ( low) , and a l bumi n 3 .2 (low) .

Tropon i n i s 19 .84 (h igh ) , PTT o f 91 .

EKG (a r ight-sided and normal EKG wa s done o n t his p at i ent ) :

EKG: 5 7 b e at s p er mi nute , n ormal s i nus rhythm . No r ma l axi s . STe levation s in inf erior leads (2 , 3 , a nd AVF) . Modera te but no tdi a g nostica l ly s igni f i can t ST e leva t ion s in V2 , V3, V4 , V5 . Ot he rwiseu n rema rka b le EKG.

Righ t -s ided EKG : ST elevat ions in 2 , 3 , a nd AVF .Po t ent i al fl a t t ening of t he T waves In leads V4 ,

Poor R-wave progre s slon.V5 , and V6 .

Chest x-ray :pericardia l

Prel i minary ,e f fus ion .

sma l l right effus ion and cardiomeg a ly v e r sus

ASSESSMENT AND PLAN : This is a n 81-year- old f e male with s ign if i c a ntcar d iovascul a r h i s t ory includ i ng an myoc a r di a l infa rction

who pre s ent s with substernal chest pain .1 . Unstabl e a ngina : Repeat EKG plus righ t-sided EKG. Troponin x 3.

CRP HS . Catheter in morning (n . p .o. at midnight ). Echo in t he morning.Ru le out d ifferen t i a l diagnosis on c hest x-ra y. Con tinue heparin d rip a tt her a peutic d osage. ASA tomor row a t dose of 325 mg ora l ly daily.Rosuvastat i n n ow a t 10 mg ora l ly da i l y ( low dose given myopathy with

History and Physicals

simvastat i n ). Beta-blockers he ld s econd ary to bradycardia . ACEinhibitors he l d secondary to increased creatinine . Morphine f or paln .

2 . Ch r oni c kidney disease : Likely sec ondary to hypertensive p lus o r minusd i a b e t i c c hanges . Creatinine at out sid e hospital 1 .7 (h a d at l e a s t 1liter o f norma l saline) . One l ite r of normal saline at 10 0 mLper hour . We will repeat creat i n i ne h e r e . NAC plus HC0 3 prior t oc on t r ast l oad tomorrow.

3 . Diabetes mellitus 2 : Glucose mon i tor i ng before meals p lus at bedtime .4 . Hype rte nsion : Lisinopril he ld secondary to i ncreased c reatinine . No

other medica t i ons s t a r t e d because t he p a t i en t ' s blood pressure normal(129 /4 9 ) .

5 . De ep venous thrombosis prophyl axi s - currently on heparin drip .6 . Ful l code .

Time Note (,

('"th n d PT('A)r 1

> 9:19:15 ***Start V itals***

• 9:26:53 bilateral Pedal pulse - +1

• 9:27 :00 Oxygen applied via nasal cannula at 2 LPM.

> 9:27:03 Fellow Paged

• 9:27:05 Fellow Arrived to cath lab

• 9:27:10 The patients Rt. Groin was prepped and drapped in a sterile fashion .

• 9:38:30 Fellow Scrubbed into procedure

• 9:38:58 Cath Attending Paged.

> 9:39:00 Cath Attending Arrived to cath lab.

• 9:43:03 1% Lidocaine injected to right Groin region area .

• 9:47:13 A micropuncture needle and wire were used to gain access.

> 9:48:35 The right femoral artery was injected and visualized for closure device placement.

• 9:48:55 A 6 JL4 was advanced with a 3mm J wire wire into the Asending Aorta .

• 9:48:59 The LCA was engaged

• 9:49:05 The Left Coronary Artery was injectied and visualized in multiple views.

> 9:52:14 The current catheter was removed and exchanged for a 6 JR4.

• 9:52:25 A 6 JR4 was advanced with a 3mm J wire wire into the Asending Aorta.

• 9:52:28 The RCA was engaged

• 9:52:35 The Right Coronary Artery was injectied and visualized in single view.

• 9:55:30 Cath Attending Scrubbed into procedure.

• 10:32:58 The Right Coronary Artery was injectied and visualized in single view.

• 10:33:23 The Right Coronary Artery was injectied and visualized in single view.

• 10:36:15 The Right Coronary Artery was injectied and visualized in single view.

• 10:39:34 The Right Coronary Artery was injectied and visualized in sing le view., 10:41:02 The Right Coronary Artery was injectied and visualized in single view.

• 10:47:14 The pt was undraped, moved to a bed and transfered to MICU.

• 10:48:05 Fluoro Notes Rm 2 : Cumulative DAP = 90482 mGy AK = 808 , Fluoro Time = 10:48 min.

• 10:48:09 Images Transfered from Philips system to Archive by RN., 10:48:23 Report was called to MICU RN.

Time Note, 10:00:29 Vista Brite Tip Guide Cath 6fr JR4 SH 100cm was utilized for the procedure

• 10:10:56A SprinterLegendRX 3.0mmx 15mm Balloon Medtronic was prepped and advanced acrossthe Prox RCA, then inflated to 8 ATM for 0:10 seconds.

• 10:15:13A EndeavorSprintRX 3.0mmx18mm Stent Medtronic was prepped and advanced across theProx RCA. The stent was deployed at 16 ATM for 0:1 0 seconds.

> 10:24 :44A Endeavor Sprint RX Coronary Stent 3.5mm x 9mm was prepped and advanced across theProx RCA1. The stent was deployed at 13 ATM for 0:10 seconds.

, 10:31 :57A Endeavor Sprint RX Coronary Stent 3.5mm x 15mm was prepped and advanced across theDist RCA. The stent was deployed at 10 ATM for 0:10 seconds.

> 10:43:10 8 Fr Angio-Seal VIP Platform Closure Device was utilized for the procedure

Post Procedure

Time Note

> 9:54:34 Catheter removed

• 10:42:35 Neuro status intact post procedue.

> 10:43:00 EKG: Post procedure is sinus bradycardia at 60 bpm .

> 10:43:04 Pain : Patient free of pain .

• 10:43:07 Pulses: unchanged., 10:47:07 Dressing: Tegaderm applied to site.

• 10:47:11 Pt tolerated procedure without complications.

• 10:47:17 CASE END

> 10:47:27 IV Fluid Total = 300mL of 0.9% NS.

> 10:47:34 Urine output: 0 mL., 10:47:37 Contrast Total. Isovue140 Lo w Osmolar

• 10:48:19 Case completed in RIS.

• 10:48:22 Post instructions: given, patient verbalizes understanding.

• 10:48:48 Transferred to Rm # 1 MICU

> 10:49:00 Complications none

> 10:49:01 Time pt leaves room.

• 11 :00:01 Time pt leaves room .

PCI

Time Note

> 10:00:46 RCA canulated with guide cath

• 10:12:18 Balloon removed, 10:20:16 Stent balloon removed

> 10:40:27 Stent balloon removed

• 10:41:13 Balloon, wire, and guide cath removed without complication.

MISC

Time Note, 10:20:15 Stent deployed successfully.

Time Note

• 10:11:12 The SprinterLegendRX 3.0mmx 15mm Balloon Medtronic was reinflated across the Prox RCA,to 10 ATM for 0:10 seconds.

> 10:11 :52 The SprinterLegendRX 3.0mmx 15mm Balloon Medtronic was reinflated across the Prox RCA,to 10 ATM for 0: 10 seconds.

, 10:15:40 The stent balloon was re-inflated across the Prox RCA to 16 ATM for 0: 15 seconds.

> 10:23:59 The Guidewire Choice PTwire was advanced across the Prox RCA1.

• 10:31:13 The stent balloon was re-inflated across the Prox RCA1 to 13 ATM for 0:20 seconds.

• 10:33:44 The stent balloon was re-inflated across the Dist RCA to 16 ATM for 0:15 seconds.

• 10:38:23 The stent balloon was re-inflated across the Dist RCA to 16 ATM for 0:15 seconds.

• 10:38:38 The stent balloon was re-inflated across the Dist RCA to 16 ATM for 0:15 seconds.

Free text notes

Time Note> 9:20:07 Heparin dc'd on arrival. Bicarb gtt infusing at 272ml/hr IV

• 9:33:23 Bicarb decreased to 91 ml/hr per order

• 9:57:45 6Fr sheath exchanged for 8fr sheath

• 10:07:31 Choice PT wire used to cross lesion to distal RCA

• 10:10:12 Pt denies cp

• 10:10:25 EKG changes noted> 10:11 :47 Pt co "heartburn" EKG changes noted.

• 10:18:07 "Heartburn still present"

• 10:45:03 Angiomax to be left on until bag is complete.

Interventional summary . " , . '

Time Action type Lesion and attributes Equipment used Action # Pressure DurationSprinterLegendR ,

10:10:56 Inflate balloon Prox RCA 3.0mmx 15mm 1 8 00:00:10BalloonMedtronic

SprinterLegendR ,10:11 :12 Reinflate balloon Prox RCA 3.0mmx 15mm 2 10 00:00:10Balloon

MedtronicSprinterLegendR}<

10:11 :52 Reinflate balloon Prox RCA 3.0mmx 15mm 3 10 00:00:10BalloonMedtronicEndeavorSprintR,

10:15:13 Place stent Prox RCA 3.0mmx18mm 4 16 00:00:10Stent MedtronicEndeavorSprintR,

10:15:40 Reinflate stent balloon Prox RCA 3.0mmx18mm 5 16 00:00:15Stent Medtronic

10:23:59 DeviceUse1 Prox RCA1 GuidewireChoice PTEndeavor Sprint

10:24:44 Place stent Prox RCA1 RX Coronary 1 13 00:00:10Stent 3.5mm x