allergies: lipitor / codeine / procardia / iodine / pepcid / catapres / humibid e / shellfish / sulfa (sulfonamides) attending: chief complaint: chest pain major surgical or invasive procedure: cardiac cath history of present illness: 89f cad c 3vd s/p stenting, mesenteric ischemia, ef 30%, ppm for sss, thrombocytosis p/w worsening angina for elective cath. she states that her anginal chest pain has become worse over the past several months. in the past week, she has anginal cp roughly twice per week, associated with sob, relieved by sl ntg with attacks occuring usually with light walking around the house, though sometimes at rest. at her baseline, she rarely leaves the house and rarely does stairs, and she becomes fatigued walking around the house. she uses a to nagivate the driveway to get to the car. on friday, she had three episodes of cp in a several hour period. she was seated after recently eating a tuna had dull pain across the chest associated with fatigue and sob. this was relieved with ntg sl, then recurred an hour later when walking to the bathroom and was relieved again with ntg. after a similar episode an hour later, she called her doctor. dr. recommended that she come in for an elective catheterization. past medical history: #. cad: 3vd s/p multiple pci #. congestive heart failure: -- echo : lvef <30%, anterior, septal, apical, distal inferior, and distal lateral severe hypokinesis to akinesis. #. 2+ mr. #. some notes mention a possible history of atrial fibrillation #. sick sinus syndrome s/p pacemaker #. hypertension #. hyperlipidemia #. essential thrombocytosis #. chronic mesenteric ischemia: mesenteric angiogram on and received stent to celiac artery origin which had 90% stenosis. pt's gi doctor is dr. at #. chronic pancreatitis #. hypothyroidism social history: lives with son, has though uses only when she leaves the house which is not frequent. patient denies any tobacco, etoh or iv drug use. significant for the absence of current tobacco use. there is no history of alcohol abuse. family history: mother - died at age 72, lung ca father - died at age 62, lung ca 3 children - 1 son w/ lung ca; daughter in there is no family history of premature coronary artery disease or sudden death. physical exam: vs: t 98.6 bp 162/54 hr 61 rr 20 30 rao2 54.8 kg gen: elderly female in 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 flat cv: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. 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. skin: petechia rle, no stasis dermatitis, ulcers, scars, or xanthomas. pertinent results: 04:50pm glucose-77 urea n-38* creat-1.7* sodium-142 potassium-5.1 chloride-111* total co2-20* anion gap-16 04:50pm estgfr-using this 04:50pm ck(cpk)-25* 04:50pm ck-mb-notdone ctropnt-<0.01 04:50pm calcium-8.8 phosphate-3.8 magnesium-2.3 iron-35 04:50pm caltibc-226* ferritin-114 trf-174* 04:50pm wbc-4.7 rbc-3.28* hgb-12.3 hct-38.6 mcv-118*# mch-37.6* mchc-32.0 rdw-20.3* 04:50pm plt count-545* 04:50pm pt-14.4* ptt-24.8 inr(pt)-1.3* 07:50am blood wbc-3.5* rbc-2.92* hgb-10.7* hct-35.4* mcv-121* mch-36.6* mchc-30.2* rdw-19.6* plt ct-584* 07:55am blood neuts-86* bands-0 lymphs-9* monos-5 eos-0 baso-0 atyps-0 metas-0 myelos-0 07:50am blood plt ct-584* 07:40am blood pt-13.8* ptt-29.1 inr(pt)-1.2* 07:50am blood glucose-78 urean-45* creat-1.5* na-143 k-5.1 cl-114* hco3-20* angap-14 03:09am blood ck(cpk)-16* 03:09am blood ck-mb-notdone ctropnt-0.01 07:50am blood mg-2.5 07:40am blood calcium-8.1* phos-3.3 mg-2.6 04:50pm blood caltibc-226* ferritn-114 trf-174* 07:16am blood type-art temp-35.6 rates-/22 o2 flow-3 po2-66* pco2-28* ph-7.41 caltco2-18* base xs--4 intubat-intubated comment-nasal 09:57pm blood lactate-2.4* 07:16am blood lactate-6.0* 12:38pm blood lactate-2.1* 08:42pm blood o2 sat-94 . . echo : conclusions: the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is low normal (lvef 50%) secondary to hypokiesis of the interventricular septum. tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). there is no ventricular septal defect. the right ventricular free wall is hypertrophied. right ventricular chamber size is normal. right ventricular systolic function is normal. there are three aortic valve leaflets. the aortic valve leaflets are moderately thickened. there is mild aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild to moderate (+) mitral regurgitation is seen. the mitral regurgitation jet is eccentric. the tricuspid valve leaflets are mildly thickened. there is moderate pulmonary artery systolic hypertension. there is a small posterolateralpericardial effusion. there are no echocardiographic signs of tamponade. . compared with the findings of the prior study (images reviewed) of , the left ventricular ejection fraction is increased. . cardiac cath : comments: 1. selective coronary angiography in this right dominant patient revealed three vessel cad. the rca was diffusely diseased with a mid occlusion. the lmca had a 30% lesion. the lad had a 90% lesion distal to the two previously placed stents. the lcx had a 80% proximal and a 80% distal lesion. 2. limited hemodynamics revealed systemic hypertension with pressures of 191/64 with hr 60 in sinus. 3. successful ptca and stnting of the rladwith a 3.00 cypher des. the final angiogram demonstrated no residual stenosis with no angiographic evidence of dissection, embolization or perforation with timi iii flow in the distal vessel. (see ptca comments) . final diagnosis: 1. three vessel coronary artery disease. 2. systemic hypertension 3. successful pci of the lad. brief hospital course: pt is a 89f cad c 3vd s/p stenting, mesenteric ischemia, ef 30%, ppm for sss, thrombocytosis p/w worsening angina for elective cath . #) cad: there is a history of 3vd with multiple previous pcis. she now presented with worsening of stable anginal symptoms for elective catheterization. the patient required ccu transfer after the catherization after developing sob during the catheterization requiring nrb mask. the cath showed a right dom. system with lmca 30% lesion, lad 90% lesion (stented with a taxus stent), lcx 80% prox/80% distal, occluded rca. the sob was suspected due to a combination of volume overload and dye reaction given her known history of shellfish allergy. she did receive appropriate pretreatment prophylaxis. cxr showed chf and she was diuresed and her volume status and creatinine improved to her baseline. she was continued on asa, plavix, bb, and nitro patch. she is not on a statin as a part of her outpatient regimen and it is notable that last her ldl was 65 on . her symptoms of chest pain remained inactive during the hospital stay. . #) rhythm: sss s/p pacer #) pump: she became volume overloaded after the catheterization as noted above and then was subsequently diuresed until she reached euvolemia. she has an ef of 30%. she was continued on her beta-blocker, though the ace was held for renal protection . #) cri: cr bumped in the setting of her clinical decompensation after the catheterisation although this subsequently returned to near baseline 1.5. she received bicarb/mucomyst pretreatment for cath and the ace was held. . #) anemia: hct remained stable. . #) essential thrombocytosis: platelets were noted to be in the 500s to 600s during the hospitalization. they were 1000 in and she was susequently controlled on outpatient hydrea. hem/onc consultants followed along during the hospital stay and in their assessment, the platelet elevation from her previous outpatient baseline was likely due to acute illness. the recommended only slight dose adjustments in the hydrea when the creatinine bumped after the clinical decompensation noted above. she will need to follow-up with heme/onc to continue to monitor wbc and platelet counts on hydrea. . # hypothyroid: c/w synthroid #) fen: cardiac diet . #) ppx: hep sc, ppi #) access: pivs #) code: full #) contacts: son home, cell medications on admission: norvasc 5 mg qam, 2.5 qhs levothyroxine 25 mcg po daily methyldopa 500 mg po 3x a day enalapril 20 mg po twice a day furosemide 40 mg po daily clopidogrel 75 mg po daily metoprolol 100 mg 1 tablets po tid aspirin 81 mg daily hydroxyurea 500 mg po one capsule q t, th hydroxyurea 500 mg two capsule po q m,w,f, sa, nitro patch loperamide 2 mg po tid as needed for diarrhea discharge medications: 1. amlodipine 5 mg tablet sig: one (1) tablet po qam (once a day (in the morning)). 2. levothyroxine 25 mcg tablet sig: one (1) tablet po daily (daily). 3. methyldopa 250 mg tablet sig: two (2) tablet po q8h (every 8 hours). 4. lasix 20 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 5. amlodipine 2.5 mg tablet sig: one (1) tablet po hs (at bedtime). 6. metoprolol tartrate 50 mg tablet sig: two (2) tablet po tid (3 times a day). 7. nitroglycerin 0.4 mg/hr patch 24 hr sig: one (1) transdermal once a day: place patch at 9pm daily, take patch off at 3pm daily. 8. clopidogrel 75 mg tablet sig: two (2) tablet po daily (daily). 9. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 10. hydroxyurea 500 mg capsule sig: one (1) capsule po qtues (every tuesday). 11. hydroxyurea 500 mg capsule sig: one (1) capsule po 6x/week (,mo,we,th,fr,sa). 12. albuterol-ipratropium 103-18 mcg/actuation aerosol sig: puffs inhalation q6h (every 6 hours). disp:*1 inh* refills:*2* discharge disposition: home with service facility: vna discharge diagnosis: angina coronary artery disease discharge condition: stable discharge instructions: weigh yourself every morning, md if weight > 3 lbs. adhere to 2 gm sodium diet . take all medications as prescribed . follow up as per below . seek medical attention immediately if you experience new symptoms including chest pain, shortness of breath, arm or jaw numbness, fainting, palpitations or other concerning symptoms. followup instructions: pcp: , . please call for a follow up appointment within 2 weeks. . provider: , md phone: date/time: 1:00 Procedure: Injection or infusion of platelet inhibitor Left heart cardiac catheterization Coronary arteriography using a single catheter Angiocardiography of right heart structures Insertion of drug-eluting coronary artery stent(s) Cranial or peripheral nerve graft Insertion of one vascular stent Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Coronary atherosclerosis of native coronary artery Mitral valve disorders Congestive heart failure, unspecified Unspecified acquired hypothyroidism Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Chronic kidney disease, unspecified Other and unspecified hyperlipidemia Other and unspecified angina pectoris Cardiac pacemaker in situ Essential thrombocythemia