Admission Date: 

Discharge Date: 

CC / Reason for admission: 

History of Present Illness:

Medications on admission: 

PMH as above
SHx: smoker, otherwise unremarkable
FHX: no family hx of CAD or DM
All: NKDA

Physical Exam:
On admission the vitals were: 150/100 HR 88 RR 22 pulse ox 96%
Lungs: CTA
CV: RRR without murmur no JVD no S3
Ext: no edema

Important Labs:
Troponin 1.5 on admission and peak of 4.75
Chem 7 normal x Cr of 1.8 on admission, peak 3.1 after IV dye, discharge Cr 1.6
CBC normal, lipids: LDL 120, HDL 35

Diagnostic Procedures/Imaging Tests: 
1)Echocardiogram: showed 

Hospital Course: 
1)CAD: 

2)


Discharge Mediations: 
Oxacillin 2 gms IVPB Q 6hours(complete1/18/04)
Lantus 18 units SQ qhs (new)
Lispro 5 units SQ with each meal (new)
Toprol XL 100mg po q day (new)
Aspirin 325mg po q day
Lipitor 20mg po q day (new)
Lisinopril on hold
Metformin stopped due to renal failure


Discharge diagnoses:
Acute STEMI s/o PTCA of RCA
Acute renal failure, multi-factorial
Staph aureus bacteremia

Condition at time of discharge:
Good

Follow-up plan/issues for the PCP: 
Patient will follow up have a basic chemistry panel done on 1/11/04. These results will be followed by his primary care MD (Dr. Smith) who is aware of the plan.  Patient will see Dr. Smith on 1/14/04.  He will follow up with his cardiologist Dr. Olsen on 1/16/04.  If Creatinine returns to norma, then his Lisinopril will be restarted at that time.  

Tests pending at time of discharge: 
2 sets of blood cultures not yet final on day of discharge, will be followed-up by Dr. Smith.

Follow-up tests: 
He is scheduled for a stress test on 1/16/04.  If this is normal he will be set up for cardiac rehab.

Discharge instructions & restrictions for the patient: 
Patient was given standard lifting instructions by cath lab.  He was told to call if recurrent chest pain, dyspnea, fever > 101 or redness at groin site.  Patient is not to drive until seen by cardiologist.