allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain major surgical or invasive procedure: cardiac catheterization s/p bms in lad/ history of present illness: mr. is a 33 year-old smoker male with a history of premature multivessel cad status post imi in treated with lcx stent, cocaine use, and a strong family history of premature cad, who presents with chest pain. of note, he was recently evaluated at for chest pain following cocaine use 3 hours prior, at which time his cardiac biomarkers revealed ck-mb 24 (mbi 12.2) and troponin 0.29. he left ama prior to further work-up. . this am, he awoke with chest pain at 0900 am, substernal in location with occasional radiation to the left shoulder. he endorses associated shortness of breath. no n/v, no diaphoresis. he denies cocaine use since . his chest pain persisted, and he presented to an osh. . there, ekg showed anterolateral st elevations. he was given asa 325 mg, ntg sl x3 without improvement, then nitroglycerin drip, and heparin iv bolus then drip. he was transferred to for further care. . in the ed, initial vitals were t 97.8, hr 68, bp 124/66, 02 99%3l, rr12. he was given metoprolol 5 mg iv, 25 mg po, plavix 300 mg po, ativan 1 mg iv, and fentanyl 50 mcg x2. he was taken directly to the cath lab for coronary angiography. . coronary angiography revealed patent lmca, lad 95% mid-thrombotic lesion and 40% distal stenosis, patent lcx including stent, proximally occluded rca with perfusion from left collaterals. he was treated with export thrombectomy, direct bare-metal stenting x2, with good angiographic results. he is being admitted to the ccu for further care. past medical history: 1. premature multivessel cad, status post imi in , status post lcx stent in . see anatomy below and most recent exercise mibi. 2. depression, previously on antidepressant currently off therapy 3. substance abuse 4. hypercholesterolemia social history: he has 3 young children from a prior relationship. he lives at home with his mother, sister and brother. does not have a close relationship with his mother or siblings. he continues to smoke. as noted above, recent cocaine use, last on . family history: per omr, his father had a first mi at 18, and died at 36 from an mi. many males on paternal side with premature cad. mother with dm, htn, throat, breast and uterine ca. physical exam: vs: afebrile, bp 117/72, hr 60 rr 10 o2 97% on ra gen: male in nad. oriented x3. tearful. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp not elevated. cv: rr, normal s1, s2. + extra heart sound, unclear if s3 or s4. no murmur appreciated. no thrills, lifts. chest: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abd: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. ext: no c/c/e. no femoral bruits. right groin cath site without hematoma, good distal pulses. 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+ . medical decision making: ekg pre-cath demonstrated nsr, rate 70 bpm, indeterminate axis, st elevation in v2-5, t wave flattening i, avl. new twi in v2-4. post-procedure ekg unchanged versus pre-cath. pertinent results: 04:20pm blood wbc-8.6 rbc-4.11* hgb-12.5* hct-34.9* mcv-85 mch-30.3 mchc-35.7* rdw-14.6 plt ct-261 04:05am blood wbc-13.2* rbc-4.90 hgb-14.6 hct-42.0 mcv-86 mch-29.9 mchc-34.8 rdw-14.7 plt ct-331 04:20pm blood neuts-67.2 lymphs-26.6 monos-4.8 eos-1.0 baso-0.4 04:20pm blood plt ct-261 10:21pm blood pt-12.1 ptt-33.5 inr(pt)-1.0 04:20pm blood glucose-100 urean-7 creat-0.5 na-133 k-3.6 cl-103 hco3-26 angap-8 04:05am blood glucose-127* urean-7 creat-0.6 na-136 k-4.3 cl-103 hco3-24 angap-13 04:20pm blood ck(cpk)-259* 10:21pm blood ck(cpk)-1112* 07:16am blood ck(cpk)-1056* 04:05am blood ck(cpk)-364* 04:20pm blood ck-mb-34* mb indx-13.1* ctropnt-0.28* 10:21pm blood ck-mb-136* mb indx-12.2* ctropnt-1.95* 07:16am blood ck-mb-58* mb indx-5.5 ctropnt-1.04* 07:16am blood calcium-9.9 phos-2.8 mg-2.3 04:20pm blood triglyc-87 hdl-37 chol/hd-5.1 ldlcalc-136* . cardiac catherization: (report not completed in omr yet) coronary angiography revealed patent lmca, lad 95% mid-thrombotic lesion and 40% distal stenosis, patent lcx including stent, proximally occluded rca with perfusion from left collaterals. he was treated with export thrombectomy, direct bare-metal stenting x2 to the lad, with good angiographic results. brief hospital course: assessment and plan, as reviewed and discussed in multidisciplinary rounds: mr. is a 33 year-old male with premature multivessel cad status post imi , status post lcx stent, admitted with anterolateral st elevation mi, status post lad bare metal stents x2 on . . 1) anterior stemi: found in the ed to have an stemi. he was immedicately taken to the catherization lab and found to have a patent lmca, lad 95% mid-thrombotic lesion and 40% distal stenosis, patent lcx including stent, proximally occluded rca with perfusion from left collaterals. he then had export thrombectomy and two bare metal stents were placed in the lad. in the hours after the procedure he still had residual (but improved) chest pain with persistent st elevations. however, after the sheath was pulled he became very agitated and wanted to leave ama. he was thought not to be competent to leave and kept with security sitter. at this time, he continued to have bleeding at the groin site, but vitals were stable and he would not lie flat as instructed or permit dressing changes. additionally, he pulled his ivs and could not be continued on integrillin/heparin (received approx 4 hours after pci). the day after the procedure he continued to have st elevations consistent with concern for a possible lv aneurysm. however, his chest pain resolved by 12 hours after stenting and he remained chest pain free for the remainder of the hospitalization. medically he was kept on aspirin, plavix, statin. additionally he was started on carvedilol and titrated up to 25 mg while inpatient with plan to transition to coreg cr. patient left prior to an echo being performed. patient has been set up with outpatient follow up with dr. and will be seeing the patient (left message at home). . 2) rhythm: nsr pre and post-cath. carvedilol increased to keep heart rate 50-60s. . 3) pump: not assessed, no signs of volume overload. . 4) hyperlipidemia: goal ldl <70 (admission labs showed elevation at 136) started high-dose statin (lipitor 80 mg daily). . 5) psych: as mentioned, patient was very agitated approx hours after catherization wanting to leave ama. intial evaluation by psychiatry felt that the patient was not competent to make medical decisions and was kept with security sitters in room. he was also given haldol and ativan as needed for agitations but never required mechanical restraints. on day 3 of hospitalization, he was found to be competent to make medical desicions and left ama. he understood clearly the risks of leaving and the importance of taking medications. he also was counselled on not using illicit drugs and seeking treatment. apparently on presentation he voiced some thoughts of suicidality but clearly stated in the days prior to leaving that he had no thoughts or plans of hurting himself. . 6) substance abuse/heroin withdrawal: he reported using heroin the day prior to admission but had not used cocaine in approx a week (urine tox confirmed this). he began to show signs of heroin withdrawal and was placed on a clonidine patch to treat this as well as scale with methadone. additionally social work discussed heroin use with the patient and recommended resuming methadone treatment. patient expressed interest in methadone clinic but said that if he could not arrange this he would start using again. additionally given his high risk for hiv/hep these serologies were sent and risk factors were discused. he will follow up with his pcp for the results. . 7) dispo: patient left ama clearly understanding the risks of further heart attacks, death or other complications. he also stated understanding that he must take aspirin and plavix. medications on admission: he describes intermittent use of asa in the past 2 months, about once every other day. he has not been taking his other medications for at least 2 months. 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. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. nitroglycerin 0.4 mg tablet, sublingual sig: tablet, sublinguals sublingual prn (as needed) as needed for chest pain. disp:*30 tablet, sublingual(s)* refills:*2* 5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed. 6. acetaminophen 325 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. disp:*30 tablet(s)* refills:*0* 7. captopril oral 8. lisinopril 20 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 9. lorazepam 1 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed for agitation/anxiety. 10. clonidine 0.1 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qsun (every sunday) as needed for opiate withdrawal. 11. carvedilol 6.25 mg tablet sig: four (4) tablet po bid (2 times a day). disp:*240 tablet(s)* refills:*2* 12. nicotine 21 mg/24 hr patch 24 hr sig: one (1) patch 24 hr transdermal daily (daily). disp:*30 patch 24 hr(s)* refills:*2* 13. methadone 10 mg/5 ml solution sig: one (1) po q2h prn () as needed for >10. discharge disposition: home discharge diagnosis: primary diagnosis: st elevation myocardial infarction. . secondary diagnoses: hypercholesterolemia depression discharge condition: afebrile, stable vital signs, tolerating pos, ambultating without assistance. discharge instructions: you were admitted with a heart attack and had removal of a clot from your heart, and a bare metal stent placed in one of the main arteries supplying blood to your heart. not all of the tests were completed to fulfill your workup and it is essential that you take your medications as prescribed. it is also pertinent that you follow-up with your pcp 7 days of discharge and that you call dr. within 2 weeks. followup instructions: please call your pcp: , . to follow-up within 7 days . please call the number for the clinic in , ma immediately following discharge . please call dr. , dept. of cardiology for an appointment within the next 2 weeks. when you call please tell them that you need to have an echocardiogram at the appointment. Procedure: Insertion of non-drug-eluting coronary artery stent(s) Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Transposition of cranial and peripheral nerves Insertion of two vascular stents Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Acute myocardial infarction of other anterior wall, initial episode of care Depressive disorder, not elsewhere classified Percutaneous transluminal coronary angioplasty status Old myocardial infarction Family history of ischemic heart disease Cocaine abuse, continuous Opioid abuse, unspecified