T6-2A INITIAL HOSPITAL SERVICES

T6-2A INITIAL HOSPITAL SERVICES
CHIEF COMPLAINT: Left-sided substernal pressure not relieved with one dose of Nitro
HISTORY OF PRESENT ILLNESS: This patient is a 69-year-old married gentleman who has long-standing history of coronary artery disease. He underwent coronary artery bypass grafting in 1982, and his most recent hospitalization for his coronary disease was March of this year. The patient indicates that at about 4 o'clock this morning he woke up with some left-sided pressure which was relieved with one dose of nitroglycerin. He seemed to be doing okay today and then about 6 tonight while watching TV he had sudden occurrence of the left-sided pressure and he took another dose of nitroglycerin, but that did not seem to help and because of that, his wife brought him to the hospital. He was not nauseated, but a little bit sweaty. He has been evaluated at clinic, and it was felt that other than the medication there were no other options available. He was not considered a candidate for heart transplant. He has been taking his medication, isosorbide 40 mg (milligram) 3 times a day; furosemide 40 mg daily; lisinopril 40 mg tablet (3/4 tablet) twice a day; enteric-coated aspirin 325 once a day; pravastatin 40 mg daily; ipratropium inhaler 4 times a day; colestipol 1 gram twice a day; atenolol 50 mg daily, and he uses some Lidex cream. He also uses Nitrostat 0.4 mg p.r.n. (as needed). He has no allergies. He is not a smoker. He does have high cholesterol treated with colestipol. He does have hypertension, which has been controlled. His exercise tolerance has gradually been diminishing.
FAMILY HISTORY: Positive for cancer
SOCIAL HISTORY: He is retired from agricultural industry where he worked as a mill operator. He lives with his wife.
REVIEW OF SYSTEMS: SKIN AND NODES: Negative. EYES: He does not have glasses. NECK: No history of thyroid or carotid disease. CHEST: See History of Present Illness. HEART: See History of Present Illness. ABDOMEN: Negative. GENITOURINARY: Negative. MUSCULOSKELETAL AND NEUROLOGIC: Negative.
PHYSICAL EXAMINATION: Generally appears slightly diaphoretic and anxious. BLOOD PRESSURE 160/80, PULSE 80, RESPIRATION 20, and O₂ (oxygen) SAT normal. CHEST is symmetrical and clear. No rales, rhonchi, or wheezing. HEART: Fairly regular rhythm with no murmur, thrill, or rubs. ABDOMEN was slightly protuberant. LIVER, KIDNEYS, AND SPLEEN nonpalpable, no masses palpable. Upper and lower EXTREMITIES no clubbing, no edema. His EKG (electrocardiogram) is stable compared to March of this year. It does show T wave inversions in 2, 3, and AVF and occasional PVCs (premature ventricular contractions). CKMB AND TROPONIN were both normal. While in the Emergency Room, he was given 2 additional doses of nitroglycerin, which did not totally resolve his pain, and so he was started on a nitroglycerin drip.
ASSESSMENT:
1. Angina.
2. Coronary artery disease.
3. Hypertension.
4. Hypercholesterolemia.
5. Chronic obstructive pulmonary disease.
PLAN:
1. Admit.
2. Nitroglycerin drip.
3. Will get serial EKG and enzymes.
4. Will increase his isosorbide to 50 mg t.i.d. (three times a day).
5. Will increase his metoprolol to 50 mg b.i.d. (twice a day).
6. Will start him on Plavix 75 mg.
T6-2A:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________