allergies: gadolinium-containing agents attending: chief complaint: chest pain major surgical or invasive procedure: cardiac catheterisation history of present illness: 55 y/o m with pmh of prostate cancer s/p xrt but no other significant past medical history and no cardiac risk factors who presents with an stemi. around 1:30 pm noted the sudden onset of chest pain and presented to where na ecg showed elevations in leads i, avl, v4-6. got asa, plavix lead, and heparin, and was transfered emergently to the cath lab where angiography demonstrated a total occlusion of the very distal lad. lv gram showed a normal ef with apical ak. an attempt was made to open the lesion with a wire as it was too small for stention or balloon angioplasty, but this was not effective. given the small area at risk, a decision was made to treat medically to avoid a potential procedural complication. post procedure the patient had some mild chest discomfort that was similar to his presenting pain. in the setting of hypertension to the 160s, the patient was started on a nitro drip with improvement of his pain, although he continues to complain of intermittent chest pain. the patient is admitted to the ccu in stable condition. in the ccu, he contiues to complain of intermettient chest pain, no palpitations, dyspnea/ abdominal pain. has been eating, drinking, urinating normally. . on review of systems, he denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. s/he denies exertional buttock or calf pain. all of the other review of systems were negative. . cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. past medical history: 1. cardiac risk factors: hypertension 2. cardiac history: none 3. other past medical history: prostate cancer s/p turp, hormonal therapy, ebrt. last psa () was at nadir at 0.2 social history: he is accompanied to this visit by his wife. is currently living in , . he is a federal auditor who works downtown. he denies a history of tobacco consumption. he notes seldom alcohol use. family history: he reports a history of throat cancer in his father diagnosed at the age of 69 and a history of prostate cancer in his paternal cousin diagnosed at the age of 60. mother and maternal uncles died of heqart disease in their 70s and 80s. physical exam: on admission: vs: 66, 140/72, 14, 100/2l nc general: nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of 7 cm. cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. no femoral bruits. tr band in place skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ left: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ at discharge: vitals: tm 100.6 at 6pm yesterday. 109-130s/60-80s, 57-64 18 99%ra 2l in >1.4out general: nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of 7 cm. cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. no femoral bruits. tr band in place. right foot tender to palpation on lateral mid dorsum of foot with mildly swollen ankle compared to left foot. extremely tender to palpation and with passive or active movement. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ left: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ pertinent results: 06:31pm blood wbc-11.0# rbc-4.94 hgb-13.1* hct-38.2* mcv-77* mch-26.6* mchc-34.3 rdw-14.6 plt ct-unable to 04:19am blood wbc-10.1 rbc-4.55* hgb-12.0* hct-34.8* mcv-77* mch-26.3* mchc-34.4 rdw-14.7 plt ct-273 04:30am blood wbc-10.2 rbc-5.46 hgb-14.3 hct-42.6 mcv-78* mch-26.2* mchc-33.6 rdw-15.0 plt ct-265 05:15am blood neuts-75.3* lymphs-15.8* monos-5.8 eos-1.9 baso-1.3 06:27pm blood pt-12.1 ptt-63.5* inr(pt)-1.1 04:19am blood pt-13.2* ptt-150* inr(pt)-1.2* 04:19am blood plt ct-273 05:15am blood pt-13.7* ptt-65.5* inr(pt)-1.3* 05:15am blood plt ct-270 06:31pm blood glucose-142* urean-14 creat-1.2 na-139 k-3.7 cl-102 hco3-23 angap-18 04:19am blood glucose-121* urean-11 creat-1.1 na-139 k-3.4 cl-105 hco3-23 angap-14 11:58am blood na-137 k-4.3 cl-105 04:30am blood glucose-101* urean-15 creat-1.4* na-140 k-4.5 cl-103 hco3-26 angap-16 05:15pm blood urean-15 creat-1.3* 05:15am blood glucose-105* urean-13 creat-1.4* na-140 k-3.9 cl-105 hco3-28 angap-11 04:19am blood ck(cpk)-5734* 11:58am blood ck(cpk)-6034* 09:00pm blood ck(cpk)-5426* 04:30am blood ck(cpk)-4517* 05:15am blood ck(cpk)-* 06:31pm blood ck-mb-9 ctropnt-0.05* 04:19am blood ck-mb-50* mb indx-0.9 ctropnt-1.03* 11:58am blood ck-mb-62* mb indx-1.0 ctropnt-1.37* 09:00pm blood ck-mb-30* mb indx-0.6 ctropnt-1.20* 04:30am blood ck-mb-18* mb indx-0.4 ctropnt-1.09* 06:31pm blood calcium-9.3 phos-2.4* mg-2.2 cholest-211* 04:19am blood calcium-8.4 phos-3.9 mg-2.0 cholest-176 04:30am blood calcium-9.5 phos-3.4 mg-1.9 05:15am blood calcium-9.0 phos-2.7 mg-1.9 uricacd-6.6 04:19am blood triglyc-38 hdl-70 chol/hd-2.5 ldlcalc-98 09:45pm urine color-yellow appear-clear sp -1.013 09:45pm urine color-straw appear-clear sp -1.010 09:45pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.5 leuks-neg 09:45pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.5 leuks-neg . cxr impression: ap chest reviewed in the absence of prior chest radiographs: normal heart, lungs, hila, mediastinum and pleural surfaces. no evidence of pneumonia or chf. . echocardiogram the left atrium is mildly dilated. no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). no masses or thrombi are seen in the left ventricle. there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the right ventricular cavity is mildly dilated with normal free wall contractility. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. no masses or vegetations are seen on the aortic valve. the mitral valve leaflets are structurally normal. there is no mitral valve prolapse. no mass or vegetation is seen on the mitral valve. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. a patent foramen ovale is present with right to left shunting of agitated saline contrast during valsalva. . lower extremity doppler ultrasound no evidence of deep venous thrombosis in right or left lower extremity. . cardiac catheterisation change for 6 french xb3 guide. the initial plan was to pass the wire as the primary reperfusion device. a pilot 50 wire was passed in a prolapsed fashion but this did not restore flow. given that the patient was pain free and the small territory at risk, it was decided to avoid further attempts at recanalization (with balloon angioplasty) given risk of dissection, perforation. the patient had intermittent chest pain at the end of the procedure and was started on iv tng and administered opiates with resolution of chest pain. he left the laboratory in stable condition. . foot xray three views show the bony structures and joint spaces to be essentially within normal limits. no dorsal swelling or evidence of erosion is appreciated. no calcaneal spurs. brief hospital course: 55 y/o m w/ pmh of prostate ca, htn, presenting with distal apical nstemi. . # apical lad stemi: distal lad thrombosis with distal apical infarct, s/p unsuccessful recanalisation during cardiac catheterisation. no other evidence of coronoary atherosclerosis was found. echocardiogram whowed preserved ef and no ventricular wall motion abnormalities. however, he was noted to have a patent formane ovale. given absence of atherosclerotic disease, pfo and known ca prostate, thromboembolic event from a possible proximal dvt remains a possible etiology for his stemi. cardiac enzymes peaked and trended down prior to discharge. he was treated with a heparin drip for 2 days after the procedure, as well as aspirin, clopidogrel, metoprolol. he was started on lisinopril and atorvastatin, but these were held in the setting of acute kidney injury. he will need to continue aspirin lifelong and clopidogrel for at least one year given his prothrombotic state. atorvastation was restarted at the time of discharge. . # s/p cath: unsuccessful attempt at wire recanalisation of distal lad. . # thromboembolism: cardiac cath shows no evidence of coronary atherosclerosis. mi site is unusual and patient has pfo, history of prostate cancer, prothrombotic state. lenis were negative, but did not include an evaluation of the iliac arteries. he will continue aspirin and plavix for anticoagulation following discharge. . # fever: etiology unclear. ua, cxr clear. urine cultures and blood cultures pending. however, timing of fever suggests possible link with gout flare. other etiologies include: infection, post-mi, thromboembolism/pe, b-symptoms from cancer. his fever curve trended down spontaneously prior to discharge. . # thigh pain - bilateral. could be from strenous workout pt reports. cks coming down but ck so out of proportion elevated compared to mb. we just started statin which can cause myopathy but states thigh pain since presentation. pt without significant cad that we know of. we held his statin, but restarted it at the time of discharge. . # : cr of 1.4 on up from baseline of 1.0. could be secondary to high ck. uric acid was 6.6, urinalysis was clear. we gave him a small fluid bolus. . # right ankle pain - most likely gout flair. pt with history of gout. a foot xray was performed which showed no pathology. his pain was controlled with percocet and colchicine. . # htn: bp was high on presentation and he was initially on a nitro drip, but this was rapidly weaned and he was treated with metoprolol instead. he was also started on lisinopril, but this was held given . he will need reevaluation . # cardiac risk factors: patient has hypertension. lipid panel was unremarkable. hba1c was pending at the time of discharge. . transitional issues: ace inhibitor was held due to creatinine elevation. please reassess hypertension and creatinine as an outpatient and consider restarting an ace inhibitor if indicated. medications on admission: benzapril 20 daily. patient not taking aspirin or vitamin d. discharge medications: 1. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 4. colchicine 0.6 mg tablet sig: one (1) tablet po daily (daily) as needed for pain. disp:*14 tablet(s)* refills:*0* 5. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for foot pain: please hold for sedation, if you feel drowsy, or if you have trouble breathing. please do not drive while taking this medication. disp:*15 tablet(s)* refills:*0* 6. atorvastatin 40 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: primary: st elevation myocardial infarction secondary: gout flare discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: mr. , it was a pleasure taking care of you at the . you were admitted with a heart attack. we performed a cardiac catheterization which showed a small blockage in the blood supply to the apex of your heart, but no other abnormalities in the blood flow to your heart. we attempted to open this blockage, but were unable to do so and did not attempy further since the reduction of heart function was very small. an echocardiogram was performed and this confirmed that your heart was beating normally. the echocardiogram also showed that you have an open flap in your heart forming an abnormal connection between the right and left sides of your heart (a patent foramen ovale). this kind of flap is found in over 10% of people. . we made the following changes to your medications: -started aspirin -started clopidogrel -started metoprolol -started atorvastatin -started oxycodone and colchicine for pain -stopped your home benzapril followup instructions: name: , : cardiology/primary care address: ,2nd fl, , phone: appointment: tuesday at 4pm department: cardiac services when: wednesday at 9:00 am with: , m.d. building: campus: east best parking: garage . please also followup with your oncologist: please call their office to make an appointment to see them within one month of this hospitalization. department: surgical specialties when: thursday at 10:30 am with: , m.d. building: campus: east best parking: garage Procedure: Coronary arteriography using two catheters Angiocardiography of left heart structures Left heart cardiac catheterization Diagnoses: Unspecified essential hypertension Acute kidney failure, unspecified Gout, unspecified Personal history of malignant neoplasm of prostate Ostium secundum type atrial septal defect Acute myocardial infarction of other specified sites, initial episode of care Personal history of irradiation, presenting hazards to health Pain in limb