Hospital Inpatient Case #2

Emergency Department Visit

Date of Visit: February 1, 2024

Chief Complaint:

Mr. John Doe presents to the emergency department with severe chest pain and shortness of breath.

History of Present Illness:

Mr. Doe is a 65-year-old gentleman with a known history of chronic kidney disease (CKD) stage 3, hypertension, hypothyroidism, CHF, and dyslipidemia, who presents with acute onset chest pain. He describes the pain as pressure-like, radiating to his left arm, and associated with shortness of breath. The pain began approximately 2 hours ago and has persisted since then. He denies any preceding symptoms or recent trauma.

Past Medical History:

CAD

Chronic Kidney Disease (Stage 3)

Hypertension

Dyslipidemia

Hypothyroidism

CHF

Medications:

Lisinopril 10 mg daily

Atorvastatin 40 mg daily

Furosemide 40 mg daily

Synthroid 88 mcg daily

Allergies:

NKDA (No Known Drug Allergies)

Social History:

Mr. Doe is a retired accountant, a lifelong non-smoker, and abstains from alcohol. He lives independently at home with his wife.

Family History:

His father had a history of myocardial infarction at the age of 70. His mother had hypertension and passed away from a stroke at the age of 75. He has two siblings with no significant medical history.

Review of Systems:

All reviewed and negative except for noted in HPI.

Physical Examination:

General: Alert and oriented, in moderate distress due to chest pain.

Vital Signs: BP 160/90 mmHg, HR 100 bpm, RR 20 breaths/min, Temp 37.8°C (febrile).

Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops. S1 and S2 normal, no additional sounds.

Respiratory: Clear to auscultation bilaterally, no wheezes or crackles.

Abdomen: Soft and non-tender, no hepatosplenomegaly.

Extremities: Warm and well perfused, no edema.

Diagnostic Studies:

ECG: Sinus rhythm, ST-segment elevation in leads II, III, aVF, and V1-V4.

Troponin: Elevated.

Assessment:

Differential diagnosis: Acute Coronary Syndrome, Acute Myocardial Infarction (MI)

Plan:

1.      Oxygen via nasal cannula to maintain oxygen saturation > 94%.

2.      Serial troponins, CK-MB, CBC, CMP, coagulation studies, and arterial blood gas (ABG).

3.      Perform a 12-lead ECG and initiate continuous cardiac monitoring.

4.      Monitor closely for signs of hemodynamic instability, arrhythmias, or other complications.

5.      Prepare for emergent transfer to the cardiac catheterization lab for coronary angiography and possible PCI.

Disposition:

Mr. Doe will be admitted to the cardiac care unit for further evaluation and management of acute myocardial infarction.

Provider Signature: [Signature]

Dr. Jane Smith, MD

Attending Physician

February 1, 2024

History and Physical

Date of Admission: February 1, 2024

Date of Examination: February 1, 2024

Chief Complaint:

Mr. John Doe presents with acute onset chest pain and shortness of breath.

History of Present Illness:

Mr. Doe is a 65-year-old gentleman with a known history of chronic kidney disease (CKD) stage 3, hypertension, and dyslipidemia, who presents to the emergency department with severe chest pain radiating to his left arm and associated dyspnea. He describes the pain as pressure-like, with an intensity of 8/10, which started approximately 2 hours ago and has been persistent since then. He denies any recent trauma or preceding symptoms. The chest pain is not relieved with rest or nitroglycerin.

Past Medical History:

CAD

Chronic Kidney Disease (Stage 3)

Hypertension

Dyslipidemia

CHF

Hypothyroidism

Medications:

Lisinopril 10 mg daily

Atorvastatin 40 mg daily

Furosemide 40 mg PO daily

Synthroid 88 mcg

Allergies:

NKDA (No Known Drug Allergies)

Social History:

Mr. Doe is a retired accountant, a lifelong non-smoker, and abstains from alcohol. He lives independently at home with his wife.

Family History:

His father had a history of myocardial infarction at the age of 70. His mother had hypertension and passed away from a stroke at the age of 75. He has two siblings with no significant medical history. 

Review of Systems:

Cardiovascular: Chest pain, shortness of breath.

Respiratory: Dyspnea on exertion.

Gastrointestinal: No nausea or vomiting.

Genitourinary: No dysuria or hematuria.

Constitutional: Fatigue.

Neurological: No weakness or numbness.

Musculoskeletal: No joint pain.

Physical Examination:

General: Alert and oriented, in moderate distress due to chest pain.

Vital Signs: BP 160/90 mmHg, HR 100 bpm, RR 20 breaths/min, Temp 98.6.

Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops. S1 and S2 normal, no additional sounds.

Respiratory: Clear to auscultation bilaterally, no wheezes or crackles.

Abdomen: Soft and non-tender, no hepatosplenomegaly.

Extremities: Warm and well perfused, no edema.

Assessment:

1.      ST-Elevation Acute Myocardial Infarction (MI)

2.      CAD

3.      CKD Stage 3

4.      Hypertension

5.      CHF (euvolemic)

6.      hypothyroidism

Plan:

1.      Cardiac biomarkers (troponin) for further evaluation of myocardial injury. Obtain cardiology consultation for consideration of coronary angiography and possible revascularization.

2.      Monitor renal function closely.

Provider Signature: [Signature]

Dr. Jane Smith, MD

Attending Physician

February 1, 20xx

Operative Report

Date of Procedure: February 1, 20xx

Procedures:

1.      Multivessel Coronary angiography

2.      Percutaneous Coronary Intervention (PCI) with Stent Placement 

Indications: Mr. John Doe is a 65-year-old gentleman with acute myocardial infarction (MI) secondary to significant stenosis of the left anterior descending artery, as demonstrated on coronary angiography. The decision for percutaneous coronary intervention (PCI) with stent placement was made to alleviate ischemic symptoms and restore coronary blood flow.

Procedure Description:

Under monitored anesthesia care, Mr. Doe was positioned supine on the cardiac catheterization table. The right femoral artery was accessed using a micropuncture technique, and a 6 French sheath was inserted.

Selective coronary angiography was performed, confirming severe stenosis of the proximal left anterior descending artery (LAD) with approximately 90% luminal narrowing. Additionally, stenosis was noted in the proximal segment of the left circumflex artery (LCx) with approximately 70% luminal narrowing. The right coronary artery (RCA) appeared patent without significant stenosis.

Fluoroscopy was utilized throughout the procedure. Following diagnostic imaging, an angioplasty balloon was advanced over a guidewire to the site of stenosis in the LAD.

Serial dilatations were performed using high-pressure balloon inflation to predilate the lesion in the LAD and optimize vessel diameter. Subsequently, a drug-eluting stent (Xience Sierra, 3.5 mm × 28 mm) was deployed across the stenotic segment of the LAD under fluoroscopic guidance. Post-dilation was performed with a non-compliant balloon to ensure adequate stent expansion and apposition.

Final angiography demonstrated excellent flow restoration in the LAD with TIMI III flow and resolution of the stenotic lesion. There were no evidence of dissection or residual stenosis.

Complications: None

Dr. John Smith, MD

Interventional Cardiologist

February 1, 20xx

Progress Note 2/2/20xx:

Subjective:

The patient reports feeling fatigued and experiencing mild discomfort at the femoral access site post-PCI. Denies any significant chest pain, dyspnea, or palpitations. Reports compliance with medications and dietary restrictions.

Objective:

Vital Signs: BP 130/80 mmHg, HR 80 bpm, RR 18 breaths/min, Temp 37°C

Cardiac Exam: Regular rate and rhythm, no murmurs, rubs, or gallops. S1 and S2 normal.

Respiratory Exam: Clear to auscultation bilaterally, no crackles or wheezes.

Labs: Troponin trending down, CBC and CMP within normal limits.

Assessment:

1.      Status Post Percutaneous Coronary Intervention (PCI): Procedure completed without immediate complications, stable post-procedure course.

2.      Acute on Chronic Renal Failure: Elevated creatinine likely related to contrast exposure, monitoring closely for worsening renal function.

3.      Hypertension: Well-controlled, no acute hypertensive crisis noted.

4.      Chronic Diastolic Heart Failure: Stable, no evidence of decompensation or acute exacerbation.

5.      Hypothyroidism: Stable, on appropriate thyroid hormone replacement therapy.

 Plan:

1.      Continue monitoring vital signs, including blood pressure and heart rate, every 4 hours.

2.      Monitor renal function closely, encourage adequate hydration to prevent contrast-induced nephropathy.

3.      Pain management: Continue with analgesia as needed for discomfort at the femoral access site.

4.      Diuretic therapy: Maintain diuresis cautiously to prevent volume overload given history of heart failure.

Progress Note 2/3/20xx:

Subjective:

The patient reports feeling significantly improved compared to admission. Denies chest pain, dyspnea, or fatigue. Expresses readiness for discharge and eagerness to return home.

Objective:

Vital Signs: Stable, BP 130/80 mmHg, HR 75 bpm, RR 16 breaths/min, Temp 37°C.

Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops. No signs of congestion on lung auscultation.

Renal Function: Creatinine trended down to [value] mg/dL, stable urine output.

Labs: Troponin within normal limits post-PCI, BNP [value] pg/mL.

Femoral Access Site: No signs of hematoma or bleeding, dressing intact.

Assessment:

1.      Status Post Percutaneous Coronary Intervention (PCI): Stable post-procedure course, no evidence of procedural complications.

2.      Acute on Chronic Renal Failure: Creatinine improving, no signs of ongoing renal injury.

3.      Hypertension: Well-controlled, no acute hypertensive crisis noted.

4.      Chronic Diastolic Heart Failure: Stable, no evidence of decompensation.

5.      Hypothyroidism: Stable, on appropriate thyroid hormone replacement therapy.

Plan:

1.      Discharge: Arrange for discharge tomorrow morning.

2.      Medication Reconciliation: Ensure patient is discharged on appropriate medications, including antiplatelet therapy, antihypertensives, diuretics, and thyroid hormone replacement.

3.      Patient Education: Review discharge instructions regarding medication regimen, follow-up appointments, signs and symptoms of worsening heart failure, and dietary sodium restriction.

4.      Follow-up: Schedule outpatient cardiology and nephrology follow-up appointments within 1 week post-discharge.

Discharge Summary

Admit Date: 2/1/xx

Discharge Date: 2/4/xx

Admitting Diagnoses:

1.      Chest pain

2.      Chronic (stage-3) Renal Failure

3.      CAD

4.      CHF

5.      HTN

6.      Hypothyroidism

Discharge Diagnoses:

1.      ST-Elevation Acute Myocardial Infarction (MI) involving the LAD artery  

2.      CAD (Coronary Artery Disease)                                                                                        

3.      Chronic (stage-3) Renal Failure                                                                                      

4.      Acute Renal Failure, Resolved                                                                                          

5.      Hypothyroidism, stable on meds                                                                                 

6.      Hypertension, stable on meds                                                                                         

7.      Chronic diastolic CHF                                                                                          

Clinical Summary:

Mr. John Doe is a 65-year-old gentleman with a past medical history significant for chronic kidney disease (CKD) stage 3, hypertension, CHF, hypothyroidism, and dyslipidemia. He presented to the emergency department on February 1, 2024, with complaints of chest pain, shortness of breath, and fever.

 Hospital Course:

Upon admission, Mr. Doe was found to have elevated cardiac enzymes consistent with an acute myocardial infarction. Coronary angiography revealed significant stenosis of the left anterior descending artery, for which he underwent successful percutaneous coronary intervention (PCI) with stent placement. Developed acute kidney injury, now resolved.

Procedures:

Angiography with Percutaneous Coronary Intervention (PCI) with stent placement

Discharge Medications:

Aspirin 81 mg daily

Clopidogrel 75 mg daily

Lisinopril 10 mg daily

Atorvastatin 40 mg daily

Furosemide 40 mg PO daily

Synthroid 88 mcg per day

Follow-up Plan:

1.      Follow-up appointment with cardiology in 1 week for post-PCI evaluation.

2.      Repeat renal function tests in 2 weeks with primary care provider.

3.      Education on medication adherence, dietary modifications, and symptom recognition.

Disposition:

Mr. Doe is discharged home with close outpatient follow-up and home health services for medication management and monitoring of renal function.

[Signature] Dr. Jane Smith, MD

Attending Physician

February 4, 20xx