Report #2829676

Overview

Sex

Male

Age

34 yrs

State

OH

Recovered

Recovered

Vaccinated

Apr 15, 2021

Onset

Jul 29, 2024

Days to onset

1201

Hospital days

3

Symptoms (82)

Symptom narrative

On July 30th, 2024, I had a heart attack due to a blood clot. I went to hospital for a successful thrombectomy and PCI of proximal to mid RCA.

Current illness

None.

Medical history

Hashimoto?s thyroiditis.

Other medications

Levothyroxin 50mcg taken once daily.

Allergies

Itching allergy to codeine.

Lab data

ED Provider Notes MD at 7/29/2024 8:08 PM History Chief Complaint Patient presents with ? Chest Pain Patient ambulates to ER with c/o chest pain, weakness and fatigue that started today. Patient presents to the ED complaining of chest pain that started around 3:00 p.m. today as he was getting towards the end of a 1-1/2 mi walk. He was trying to get back to exercising after having neck surgery a few weeks ago. He states he has not walked that much in a month or more. He started having midsternal chest pain that he rates a 7/10. Describes it as "like severe heartburn". He also reports feeling short of breath as well as a little lightheaded. States he did feel like his heart was racing fast earlier but that is sensation is now gone. He has had some nausea but has not vomited. Denies any leg swelling. His mother gave him some Tums in case it was acid indigestion but had no relief from that. He also took an omeprazole which did not help. He denies any cardiac history. He states he only time he has felt like this was when he took pain medication and a muscle relaxer simultaneously. Past Medical History: Diagnosis Date ? Abdominal pain, chronic, right lower quadrant ? Adult acne ? Cataract associated with other disorder dislocated crystalline lens OD ? Congenital glaucoma OU ? Congenital glaucoma 04/25/2013 ? DJD (degenerative joint disease) 12/21/2021 ? Endophthalmitis left eye ? Exacerbation of asthma 01/06/2023 ? Exacerbation of asthma 01/06/2023 ? GERD (gastroesophageal reflux disease) ? Groin pain ? History of bilateral inguinal hernia repair ? Hyperlipidemia ? IDA (iron deficiency anemia) 08/02/2022 ? Inguinal hernia ? Iron deficiency 06/2018 pt received 2 iron infusions in 2018 ? OSA (obstructive sleep apnea) 02/11/2020 not a problem now ? Retinal detachment ? Subclinical hypothyroidism 01/06/2023 Family History Problem Relation Age of Onset ? No known problems Mother ? No known problems Father Social History Tobacco Use ? Smoking status: Never Passive exposure: Never ? Smokeless tobacco: Never Vaping Use ? Vaping status: Never Used Substance Use Topics ? Alcohol use: Yes Alcohol/week: 1.0 standard drink of alcohol Types: 1 Standard drinks or equivalent per week Comment: Occasional ? Drug use: No Allergies Allergen Reactions ? Codeine Itching Can take with benadryl ? Hydrocodone Itching Can take with benadryl ? Oxycodone Itching Can take with benadryl Current Outpatient Medications Medication Sig ? acetaminophen 650 MG Tab CR Take 1 tablet by mouth every 6 hours as needed for Mild Pain. ? Levothyroxine Sodium 50 MCG capsule Take 1 capsule by mouth daily. ? oxyCODONE 5 MG tablet Take 1 tablet by mouth every 6 hours as needed for Moderate Pain for up to 7 days. ? Pantoprazole 40 MG Tab DR tablet DR Take 1 tablet by mouth daily. ? Polyethylene glycol 17 g Pack packet Take 1 packet by mouth every 12 hours. ? Senna 8.6 MG tablet Take 1 tablet by mouth every 12 hours. Review of Systems Constitutional: Positive for diaphoresis. Negative for chills, fatigue and fever. HENT: Negative for congestion, ear pain, mouth sores, nosebleeds, rhinorrhea, sore throat and voice change. Eyes: Negative for discharge. Respiratory: Positive for shortness of breath. Negative for cough and wheezing. Cardiovascular: Positive for chest pain and palpitations. Negative for leg swelling. Gastrointestinal: Positive for nausea. Negative for abdominal distention, abdominal pain, constipation, diarrhea and vomiting. Endocrine: Negative for cold intolerance. Genitourinary: Negative for difficulty urinating, flank pain, hematuria and urgency. Musculoskeletal: Negative for arthralgias and back pain. Allergic/Immunologic: Negative. Neurological: Positive for light-headedness. Negative for syncope, speech difficulty, weakness and numbness. Hematological: Negative for adenopathy. Psychiatric/Behavioral: Negative for agitation. Physical Exam BP 121/87 | Pulse 89 | Temp 98.3 °F (36.8 °C) (Oral) | Resp 14 | Ht 1.778 m (5' 10") | Wt 79.7 kg (175 lb 9.6 oz) | SpO2 99% | BMI 25.20 kg/m² | Smoking Status Never Physical Exam Vitals and nursing note reviewed. Constitutional: General: He is not in acute distress. Appearance: Normal appearance. He is normal weight. He is not ill-appearing. HENT: Head: Normocephalic and atraumatic. Nose: Nose normal. Mouth/Throat: Mouth: Mucous membranes are moist. Pharynx: Oropharynx is clear. Cardiovascular: Rate and Rhythm: Normal rate and regular rhythm. Pulmonary: Effort: Pulmonary effort is normal. Breath sounds: Normal breath sounds. Abdominal: General: Abdomen is flat. Bowel sounds are normal. Palpations: Abdomen is soft. Musculoskeletal: General: Normal range of motion. Cervical back: Normal range of motion and neck supple. Right lower leg: No edema. Left lower leg: No edema. Skin: General: Skin is warm and dry. Capillary Refill: Capillary refill takes less than 2 seconds. Neurological: General: No focal deficit present. Mental Status: He is alert and oriented to person, place, and time. Cranial Nerves: No cranial nerve deficit. Motor: No weakness. Psychiatric: Mood and Affect: Mood normal. Behavior: Behavior normal. ED Course ED Course as of 07/29/24 2202 Mon Jul 29, 2024 2012 Patient presents to the ED complaining of chest pain, shortness of breath and lightheadedness that developed at the end of a 1-1/2 mi walk today. On arrival he is afebrile and hemodynamically stable but diaphoretic. Physical exam is benign. Concerns or for a first-time cardiac event versus dehydration and heat exhaustion given the recent increase in exercise outdoors. Will perform cardiac workup and give IV fluids along with medication for acid indigestion and nausea. 2013 EKG performed at 8:02 p.m. and reviewed by me shows sinus rhythm at a rate of 59. PR interval 164, QT interval 432, QTC interval 428. There are 2 T-wave inversions in 2 3 and AVF along with V5 and V6. No ST elevations. He has cardiac tracings on file but no prior 12 leads for comparison. 2046 CBC shows a leukocytosis of 17,000. BMP is unremarkable other than a random glucose of 128. BNP is normal along with coags however troponin is positive at 245. This would be consistent with his ST depressions indicative of an MI. Will start heparin, notify Cardiology and make arrangements for transfer and admission. 2103 I spoke to Cardiology who just recommended controlling patient's pain with morphine and nitro drip if necessary and blood pressure will allow, heparin drip and transfer to Medical Center with close monitoring of his EKG. Will submit bed request. 2200 Patient has been accepted by the hospitalist at Medical Center. We are making transportation arrangements at this time. Repeat troponin is 585. Procedures Medical Decision Making Amount and/or Complexity of Data Reviewed Independent Historian: parent Labs: ordered. Radiology: ordered. ECG/medicine tests: ordered. Risk Prescription drug management. Laboratory & Radiological Imaging (if done): Results for orders placed or performed during the hospital encounter of 07/29/24 CBC AND ELECTRONIC DIFF Result Value Ref Range WBC Count 17.2 (H) 4.3 - 11.1 K/uL RBC Count 5.89 (H) 4.19 - 5.50 M/uL Hemoglobin 15.7 12.9 - 16.9 g/dL Hematocrit 46.9 37.5 - 50.1 % Mean Cell Volume 79.6 (L) 83.0 - 100.0 fL Mean Cell Hgb 26.7 (L) 28.0 - 33.0 pg Mean Cell Hgb Conc 33.5 31.6 - 35.5 g/dL RBC Distribution 13.4 11.5 - 14.5 % Platelet Count 282 140 - 400 K/uL Mean Platelet Volume 11.9 9.4 - 12.4 fL Segs + Bands Auto 85.1 % Immature Grans % 0.3 % Lymphocyte % Auto 10.2 % Monocyte % Auto 4.1 % Eosinophil % Auto 0.1 % Basophil % Auto 0.2 % Segs + Bands,Absolute Auto 14.7 (H) 1.6 - 8.9 K/uL Abs Lymph Auto 1.8 0.6 - 4.6 K/uL Abs Mono Auto 0.7 0.0 - 1.3 K/uL Abs Eos Auto 0.0 0.0 - 0.6 K/uL Abs Baso Auto 0.0 0.0 - 0.2 K/uL Nucleated RBC 0 /100 WBC BASIC METABOLIC PANEL Result Value Ref Range Sodium 139 136 - 145 mmol/L Potassium 4.4 3.5 - 5.1 mmol/L Chloride 104 98 - 107 mmol/L Carbon Dioxide 19 (L) 23 - 29 mmol/L BUN 18 6 - 20 mg/dL Creatinine 0.91 0.70 - 1.30 mg/dL Glucose 128 (H) 70 - 105 mg/dL Calcium 10.3 8.6 - 10.3 mg/dL BUN/CREA Ratio 20 6 - 26 Osmolality (Calc) 292 280 - 300 eGFR, CKD-EPI, Male >90 >=60 mL/min/1.73m2 PROTIME-INR Result Value Ref Range PT 12.0 9.4 - 12.1 sec INR 1.1 PTT Result Value Ref Range PTT 31.1 26.0 - 36.0 sec B-TYPE NATRIURETIC PEPTIDE (BRAIN) Result Value Ref Range B-Type Natriuretic Peptide 18 <=100 pg/mL TROPONIN I INITIAL Result Value Ref Range hs-Troponin I 245 (HH) <21 ng/L TROPONIN 1 HOUR Result Value Ref Range 1 Hour hs-Troponin 585 (HH) <21 ng/L Delta hs-Troponin I 340 (H) ng/L ANTI XA HEPARIN (UNFRACTIONATED) Result Value Ref Range Anti Xa Heparin (Unfractionated) <0.04 (L) 0.30 - 0.70 IU/mL URINE DIPSTICK; REFLEX MICROSCOPY; REFLEX CULTURE PERFORMABLE Result Value Ref Range Color Light Yellow Yellow Appearance Urine Clear Clear Glucose Urine Normal Normal Ketones Urine 40 mg/dL (A) Negative Urine Bilirubin Negative Negative Specific Gravity Urine >1.030 (H) 1.010 - 1.025 Blood Urine Negative Negative pH Urine 6.0 5.0 - 8.0 pH Units Protein Urine Trace Negative-Trace mg/dL Urobilinogen Urine Normal Normal Nitrites Urine Negative Negative Leukocyte Esterase Negative Negative XR CHEST 1 VIEW PORTABLE Final Result IMPRESSION: No acute cardiopulmonary abnormality. Clinical Impression: 1. NSTEMI (non-ST elevated myocardial infarction) Disposition: Home or Self Care Discharge Instructions None There are no outpatient Patient Instructions on file for this admission. New Prescriptions No medications on file