Admission Dx: Three-vessel coronary artery disease, non-Q-wave MI, hypertension, CHF, and hypercholesterolemia.
HPI: This is a 64-year-old white male transferred from a local hospital. The patient had a four day history of substernal nonradiating chest pain which occurred with exertion and walking one block. This pain was relieved with five minutes of rest. The patient continued to have episodes like this, and then presented to the hospital ER on the morning of Aug 24, 1997. The pt refused coronary catheterization at this time. The pt continued to have unstable angina and on the evening of the 30th, the pt sustained a non-Q-wave MI. After this, the pt agreed to have the coronary catheter. In the interim, the pt developed pulmonary edema. Based upon the pts three-vessel coronary artery disease and his ongoing symptoms of ischemia, he was transferred to a tertiary care center to undergo coronary artery bypass graft procedure.
PMH: Hypertension, Hypercholesterolemia, Glomerulonephritis, Migraine headaches, Hypothyroidism, Hemorrhoidectomy 1978
Allergies: IV contrast dye
SH: no ETOH no tobacco
FH: Family history is noncontributory
|PE:||Temp 37.1° C||HR 60||RR 20||BP 131/68|
|ROS:||HEENT: PERRLA, normocephalic and atraumatic|
|CV: sinus rhythm, normal rate, w/o murmurs, rubs, or gallops|
|BS: coarse bilateral|
|ABD: soft nontender|