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PATIENT:Â CAPOZZI, VINCENT
ACCOUNT/EHR #:Â CAPOVI001
DATE:Â 08/11/18
Attending Physician:Â Willard B. Reader, MD
Patient is a 62-year-old male previously seen by Dr. David Bush 18 months ago. The patient has a history of coronary artery disease and hyperlipidemia. He underwent coronary bypass surgery in 1993 by Dr. Howard that involved a left internal mammary artery to left anterior descending. In 2013, he underwent a redo operation consisting of a right internal mammary artery to left anterior descending, saphenous vein graft to circumflex, and saphenous vein graft to right coronary artery.
He did well until yesterday afternoon, when he developed an episode of moderate retrosternal chest pressure radiating to the right shoulder, which was prolonged and lasted until 3:00 a.m., at which time he presented to the ED. He apparently was given one nitroglycerin sublingual, with resolution of symptoms.
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The patient is currently asymptomatic on examination and his review of systems is noncontributory.
PE:Â He is alert, oriented times three, in no acute distress. HEENT: unremarkable. Lungs: clear. Cardiovascular: Regular rate and rhythm. No murmurs and no gallops. Abdomen: Benign. Extremities: No edema. EKG: Normal sinus rhythm with myocardial changes. Venipuncture and Lab tests completed here, today: Lipid panel: all unremarkable except for a cholesterol of 255. CBC: within normal limits. PT and PTT within normal limits. Cardiac enzymes times one: negative. Radiology report states chest x-ray, single view, frontal, unremarkable.
Admitting DX:Â Prolonged chest pain with negative electrocardiogram and negative enzymes times one.Â
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Admit for observation to Telemetry. In view of the atypical nature of prolonged chest pain, we will proceed with a screening Cardiolite stress test later today. Nitroglycerin paste was applied on admission; however, it will be held until the stress test is completed. One aspirin a day was started. Further recommendation and interventions will depend on the results from the stress test.
Discharge DX:Â Coronary atherosclerosis of native coronary artery
Willard B. Reader, MD
WBR/pw D: 08/11/18 09:50:16 T: 08/13/18 12:55:01
Diagnosis code(s)? Procedure Code(s)?
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