DISCHARGE SUMMARY
ADMISSION DIAGNOSES
1. Preinfarction angina.
2. Secondary arteriosclerotic heart disease.
FINAL DIAGNOSES
1. Preinfarction angina.
2. Secondary arteriosclerotic heart disease.
A 64-year-old white male with a longstanding history of ASHD, intermittent episodes of chest pain for sometime. Has a known positive treadmill. Has been on Procardia and Sorbitrate, but stopped Sorbitrate because of headaches. During the past
24 hours, he has noticed some increase in his pain and has had 5 separate episodes lasting 10 to 15 minutes each, which usually respond to nitroglycerin. Because of this problem and the increasing severity of the pain, he was admitted to the hospital with a blood pressure of 140/70, pulse 60 and regular, respirations were 14. Lungs were clear. Heart regular sinus rhythm, sounds were of pretty good quality.
24 hours, he has noticed some increase in his pain and has had 5 separate episodes lasting 10 to 15 minutes each, which usually respond to nitroglycerin. Because of this problem and the increasing severity of the pain, he was admitted to the hospital with a blood pressure of 140/70, pulse 60 and regular, respirations were 14. Lungs were clear. Heart regular sinus rhythm, sounds were of pretty good quality.
The patient was seen in the office, admitted to the hospital where an admission panel revealed only a BUN of 23.8, the CPK isoenzymes were normal. Chest x-ray was essentially unremarkable. Initial ECG was consistent with his disease, and following discussion with a cardiologist, the patient was transferred with the diagnosis of preinfarction angina for studies and possible corrective procedure.
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