


Record date: ****-**-**

 

SDU JAR Admission Note

Name: 	 ***** ********
MR:	*******
DOA:  	*/**/**
PCP:  ******* *****
Attending: ******
CODE: FULL

HPI:  70 yo M with NIDDM admitted for cath after positive MIBI. Pt has had increasing CP and SOB on exertion for past two months, seen at PCP on */** with EKG showing RBBB. Pt was scheduled for stress MIBI today to eval for cardiac ischemia. MIBI was reportedly stopped 2/2 to chest pain, though pt denies having pain during procedure. MIBI was read as positive for moderate to severe inferior ischemia and pt was referred to the ED for admission and catheterization.


PMH: 
Seronegative Rheumatoid Arthritis 
HTN
Right Carotid Artery Dz 
Obesity 
Hyperlipidemia 
Diabetes mellitus type 2

Home Medications: 

Acetylsalicylic Acid (Aspirin)  PO 81 MG QD
Xanax (Alprazolam)  PO  BID
Atenolol  PO 50 MG QD
Enalapril Maleate  PO 10 MG QD
Hctz (Hydrochlorothiazide)  PO  QD
Metformin  PO 850 MG BID


Allergies: NKDA


Social History:  Smokes 2 packs per month, drinks 1 case of beer per month


Exam:  	
VS: T: 98.1  HR: 59  BP: 158/72  RR: 20  Sat:  97% RA
General: Obese gentleman lying comfortably in bed
HEENT: Pupils equal, round, and reactive to light, extra ocular muscles intact, pharynx clear
Pulmonary: Clear to auscultation bilaterally, no wheezes, rubs or rales 
Cardiac:  Irregular, no m/r/g, no jugular venous distension
Abdomen: soft, nt, nd, normal bowl sounds
Extr: Positive pedal pulses bilaterally, no cyanosis, clubbing, or edema  
Neuro: Alert and oriented to person place and time. No focal weakness or paresthesias.


DATA: 

NA        	138       	          	          	          
K         	3.9      	          	          	          
CL        	99(L)     		          	          	          
CO2       	27.8      		          	          	          
BUN       	16        	          	          	          
CRE       	0.9       		          	          	          
GLU       	95                  	          	           

WBC       	9.9       	          	          	          	          
RBC       	5.14      	          	          	          	          
HGB       	15.7      	          	          	          	          
HCT       	44.5      	          	          	          	          
MCV       	87        	          	          	          	          
MCH       	30.6      	          	          	          	          
MCHC      35.4      	          	          	          	          
PLT       	243       	          	          	          	          
RDW       	13.4      

PT        	12.2      	          	          	          	          
PT-INR    	1.1       	          	          	          	          
PTT       	24.8      	          	          	          	          

MIBI: The patient has reduced exercise capacity (5 METS).  The ECG is positive for ischemia.  LV contractile function is normal. Findings are consistent with moderate to severe ischemia in the inferior and inferolateral ischemia at low work load (1.5 min EX). The LVEF is 52%.

EKG: Sinus arrhythmia with RBBB

ASSESSMENT AND PLAN: 

70 yo M with multiple cardiac risk factors and 2 mo escalating angina sx presents with MIBI positive for interior and inferiolateral ischemia.

CV:
	Ischemia: Hx angina, MIBI positive for inferior and inferiolateral ischemia. 
Cycle enzymes, plan for cath */** to eval for reversible coronary defect. ASA.
	Pump: EF estimated at 52%
Cont enalapril, hctz
Rhythm: Sinus arrythmia and RBBB
Hold atenolol for bradycardia
DM
RISS
Prophy:
DVT prophylaxis: ambulatory
GI prophylaxis: Zantac


_______________________
**** ****, MD, EHMS pager *****




