The patient was in his usual state of health until April 24 when he experienced right-sided chest pain after 10 minutes of bicycling exercise at YMCA .

The patient did report that he took a couple of Tylenol to try to help with the chest pain symptoms .

On the day of admission , the patient went for a brisk walk with his caretaker .

At his baseline , the patient 's exercise tolerance was walking on flat ground for 2 blocks and climbing 7 stairs .

His exercise capability was mainly limited by shortness of breath , exertion , as well as chronic osteoarthritis in both of his knees .

Status post right-sided carotid endarterectomy in October 1999 .

Status post hemorrhoid surgery 10 years ago .

Status post cholecystectomy 15 years ago .

He denied any illicit drug use history .

NO KNOWN DRUG ALLERGIES .

REVIEW OF SYSTEMS :

PHYSICAL EXAMINATION :

HEENT : Pupils equal , round , and reactive to light .

NECK : Supple , no prominent jugular venous distention .

LUNGS : Slightly decreased breath sounds at left lung base .

Active bowel sounds .

RECTAL : Revised guaiac was negative .

On admission , his sodium was 148 , potassium 4.3 , chloride 99 , bicarb 29 , BUN 27 , creatinine 1.2 , glucose 107 .

WBC 9.3 , hemoglobin 15.9 , hematocrit 47.4 , platelets 245,000 , with 56 neutrophils and 34 lymphocytes .

First set of cardiac enzymes was as following : CK 92 , CK MB 9.15 , index 9.9 , troponin T 0.04 and myoglobin 51 , INR 3.2 , PT 34.3 , PTT 62.6 , digoxin level 0.7 .

Chest x-ray on admission showed slight haziness over left hemidiaphragm suggestive of a small pleural effusion , mild congestive heart failure , and questionable right hilar opacity suggestive either of pulmonary vessels or hilar lymphadenopathy .

EKG on admission showed atrial fibrillation at a rate of 80 , Q wave at 3 and aVF , very slight ST depression at V2 to V 4 with < 0.5-mm flat T waves at aVF and T wave inversion at 3 .

ASSESSMENT AND PLAN :

The patient was admitted to a monitored bed at the cardiac surveillance unit initially to rule out myocardial infarction .

We enrolled the patient in the new enrollment study , ROMANCE , for cardiac enzyme monitor , with the patient's consent .

Since the patient is already on diltiazem and Digoxin , with heart rate in the 60s and 70s , we did not add beta blocker upon admission .

After the patient was admitted to the cardiac surveillance unit , he complained about continued chest pain , around 4 : 00 p.m. and rated at about 4-5/10 .

A repeat EKG at that time showed atrial fibrillation at a rate of 72 with T wave inversion 3 and aVF , ST depression V2 to V 6 of 1 mm as well as T flattening in V 5 and V 6 .

We did not start the patient on heparin on admission because both his PT and PTT were already elevated .

His PTT was about 60 , at the therapeutic range of anticoagulation .

We also transferred the patient from the cardiac surveillance unit to coronary care unit for more intensive hemodynamic monitoring .

We will address the issue of whether or not to perform cardiac catheterization on the patient in the a.m. The patient also had a stress echo ordered earlier during the day .

In addition , we will also check the patient 's fasting lipid panel as well as hemoglobin A1C to better risk stratify his coronary artery disease .

On admission , the patient showed no signs of frank congestive heart failure .

His chest x-ray did show very mild signs of pulmonary edema .

This level was within normal limits on admission .

His heart rate was in 60s to 80s on admission .

His coagulation parameter was also checked on admission , his INR was 3.2 , which was slightly above the target range , which should be between 2 and 3 .

We have temporarily held his Coumadin and will recheck a coag tomorrow morning .

The reason for his elevation of PTTs is not clear to us at this moment .

We will send for a liver function tests in the morning as well .

We have placed him on Lipitor 10 mg p.o. q.d. as an inpatient as per pharmacy recommendation .

Cerebrovascular accident , status post revised cerebrovascular accident .

The patient is an 83-year-old Caucasian man with a past medical history of hypertension , congestive heart failure , atrial fibrillation , and hypercholesterolemia , who presents with chest pain .

Mr. Jones is an 83-year-old man with past medical history of hypertension , congestive heart failure , atrial fibrillation , hypercholesterolemia , history of CVA who presented to Stanford Emergency Room on April 25 with chief complaint of right-sided chest pain since April 24 .

He denied any further chest pain at night .

After 10 minutes of brisk walking , the patient once again experienced right-sided chest pain with radiation to the right scapular area .

The patient denied symptoms of shortness of breath , nausea , vomiting , or excessive sweating .

He also denied pleuritic chest pain or tearing sensation .

He denied any weight gain , increase in abdominal girth , or peripheral edema symptoms .

He currently works as a tour guide at the YMCA .

He denied any history of tobacco use in the past .

He denied any illicit drug use history .

His father died at age 63 of a heart attack .

His mother died at age 86 of pneumonia and complications from congestive heart failure .

REVIEW OF SYSTEMS :

The patient denied any change in weight or appetite .

He did recall that he has been feeling more fatigued lately .

He denied any other gastrointestinal or genitourinary symptoms .

VITAL SIGNS : Temperature 36 degrees centigrade , pulse 75 , blood pressure 125/88 , respirations 20 , 98% at room air , repeat blood pressure of right arm was 106/72 and left arm 117/69 with heart rate 65 .

GENERAL : This is an elderly Caucasian gentleman appearing younger than his stated age in no acute distress .

LUNGS : Slightly decreased breath sounds at left lung base .

CARDIOVASCULAR : Irregularly irregular rhythm with a 2+ / 6 systolic murmur heard prominent at left sternal border with radiation to axilla .

Active bowel sounds .

First set of cardiac enzymes was as following : CK 92 , CK MB 9.15 , index 9.9 , troponin T 0.04 and myoglobin 51 , INR 3.2 , PT 34.3 , PTT 62.6 , digoxin level 0.7 .

EKG on admission showed atrial fibrillation at a rate of 80 , Q wave at 3 and aVF , very slight ST depression at V2 to V 4 with < 0.5-mm flat T waves at aVF and T wave inversion at 3 .

Mr. Jones is an 83-year-old man with history of hypertension , congestive heart failure , atrial fibrillation , and hypercholesterolemia , who presents with chest pain of acute onset .

We enrolled the patient in the new enrollment study , ROMANCE , for cardiac enzyme monitor , with the patient's consent .

The patient responded to the nitroglycerin drip partially but not completely .

If the patient further develops signs of congestive heart failure , we will consider the use of diuretics .

The patient is an 83-year-old Caucasian man with a past medical history of hypertension , congestive heart failure , atrial fibrillation , and hypercholesterolemia , who presents with chest pain .

HISTORY OF PRESENT ILLNESS :

Mr. Jones is an 83-year-old man with past medical history of hypertension , congestive heart failure , atrial fibrillation , hypercholesterolemia , history of CVA who presented to Stanford Emergency Room on April 25 with chief complaint of right-sided chest pain since April 24 .

The patient was in his usual state of health until April 24 when he experienced right-sided chest pain after 10 minutes of bicycling exercise at YMCA .

He described the chest pain as a dull ache in the right side of his chest radiating posteriorly to the right scapular area .

The chest pain lasted about 3 minutes and resolved with rest .

That same night , the patient once again experienced right-sided chest pain while lying in bed right before he went to sleep .

He describes the pain as right-sided chest pain with same radiation to posterior at an intensity of 6-7 out of 10 .

The chest pain lasted about 10 minutes and resolved spontaneously .

The patient did report that he took a couple of Tylenol to try to help with the chest pain symptoms .

He denied any further chest pain at night .

On the day of admission , the patient went for a brisk walk with his caretaker .

After 10 minutes of brisk walking , the patient once again experienced right-sided chest pain with radiation to the right scapular area .

He rated the intensity of the pain at 8 out of 10 .

The chest pain was associated with mid-chest pressure , which was new to him .

The patient denied symptoms of shortness of breath , nausea , vomiting , or excessive sweating .

He also denied pleuritic chest pain or tearing sensation .

However , the chest pain persisted , and the patient had to cancel his lunch plans at the YMCA .

He asked his wife to pick him up at the YMCA , and he eventually came to the Stanford University Emergency Room with chief complaint of chest pain at a little past noon .

At the time of presentation , he rated his chest pain intensity at 7 out of 10 .

At Stanford Emergency Room , the patient was given nitroglycerin x 2 , 1 regular aspirin , and a GI Cocktail , which partially relieved his symptoms .

When the cardiology team went to see the patient , he rated his chest pain at 4 out of 10 .

After the 3rd sublingual nitroglycerin and 2 mg IV morphine , the patient reported that his chest pain completely went away .

At his baseline , the patient 's exercise tolerance was walking on flat ground for 2 blocks and climbing 7 stairs .

His exercise capability was mainly limited by shortness of breath , exertion , as well as chronic osteoarthritis in both of his knees .

The patient did report that he had 2- pillow orthopnea and symptoms of paroxysmal nocturnal dyspnea , which seems to occur about once a week recently .

He denied any weight gain , increase in abdominal girth , or peripheral edema symptoms .

Hypertension for many years .

Congestive heart failure , which was diagnosed about 3 years ago .

Chronic atrial fibrillation , on Coumadin for anticoagulation .

Hypercholesterolemia .

Status post cerebrovascular accident , _ _ _ _ _ _ VA in March 1999 .

Osteoarthritis of the knees .

Status post hemorrhoid surgery 10 years ago .

He used to work in the insurance business but retired over 20 years ago .

He used to drink alcohol at social settings but completely quit drinking alcohol about 15 years ago .

He denied any illicit drug use history .

His father died at age 63 of a heart attack .

His mother died at age 86 of pneumonia and complications from congestive heart failure .

ALLERGIES :

NO KNOWN DRUG ALLERGIES .

Celebrex 100 mg p.o. b.i.d. p.r.n. joint pain .

For positive cardiopulmonary symptoms , please refer to the history of present illness .

He denied any other gastrointestinal or genitourinary symptoms .

VITAL SIGNS : Temperature 36 degrees centigrade , pulse 75 , blood pressure 125/88 , respirations 20 , 98% at room air , repeat blood pressure of right arm was 106/72 and left arm 117/69 with heart rate 65 .

GENERAL : This is an elderly Caucasian gentleman appearing younger than his stated age in no acute distress .

SKIN : Shows normal color and turgor .

HEENT : Pupils equal , round , and reactive to light .

No throat erythema .

No cervical lymphadenopathy .

LUNGS : Slightly decreased breath sounds at left lung base .

CARDIOVASCULAR : Irregularly irregular rhythm with a 2+ / 6 systolic murmur heard prominent at left sternal border with radiation to axilla .

ABDOMEN : Soft , nontender , nondistended .

Liver edge about 1 cm below costal margin .

No splenomegaly .

NEUROLOGIC : Alert and awake .

Strength and sensation are intact except for mild left hemiparesis with arm greater than legs .

Reflex was symmetrical .

Chest x-ray on admission showed slight haziness over left hemidiaphragm suggestive of a small pleural effusion , mild congestive heart failure , and questionable right hilar opacity suggestive either of pulmonary vessels or hilar lymphadenopathy .

EKG on admission showed atrial fibrillation at a rate of 80 , Q wave at 3 and aVF , very slight ST depression at V2 to V 4 with < 0.5-mm flat T waves at aVF and T wave inversion at 3 .

Mr. Jones is an 83-year-old man with history of hypertension , congestive heart failure , atrial fibrillation , and hypercholesterolemia , who presents with chest pain of acute onset .

He was admitted to the cardiology team to rule out myocardial infarction .

PLAN BY PROBLEMS :

Coronary artery disease .

The patient 's risk factors for coronary artery disease includes hypertension , hypercholesterolemia , and positive family history of coronary artery disease .

The patient was admitted to a monitored bed at the cardiac surveillance unit initially to rule out myocardial infarction .

The patient was given baby aspirin 81 mg p.o. q.d. as well as nitroglycerin paste 1.5 inches at anterior chest wall q.6h. in addition to nitroglycerin sublingual p.r.n. chest pain .

The patient was also given oxygen via nasal cannula to maximize his oxygen supply .

After the patient was admitted to the cardiac surveillance unit , he complained about continued chest pain , around 4 : 00 p.m. and rated at about 4-5/10 .

A repeat EKG at that time showed atrial fibrillation at a rate of 72 with T wave inversion 3 and aVF , ST depression V2 to V 6 of 1 mm as well as T flattening in V 5 and V 6 .

We also transferred the patient from the cardiac surveillance unit to coronary care unit for more intensive hemodynamic monitoring .

We will address the issue of whether or not to perform cardiac catheterization on the patient in the a.m. The patient also had a stress echo ordered earlier during the day .

In addition , we will also check the patient 's fasting lipid panel as well as hemoglobin A1C to better risk stratify his coronary artery disease .

Congestive heart failure .

On admission , the patient showed no signs of frank congestive heart failure .

He did not have peripheral edemas .

His chest x-ray did show very mild signs of pulmonary edema .

We decided to keep the patient 's fluid even at this time .

If the patient further develops signs of congestive heart failure , we will consider the use of diuretics .

Hypertension .

Chronic atrial fibrillation .

His coagulation parameter was also checked on admission , his INR was 3.2 , which was slightly above the target range , which should be between 2 and 3 .

Hypercholesterolemia .

Cerebrovascular accident , status post revised cerebrovascular accident .

Code status DNR , DNI .