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PATIENT MEDICAL RECORD Memorial Hospital Medical Center 123 Medical Center Blvd, Boston, MA 02118 CONFIDENTIAL - FOR MEDICAL PERSONNEL ONLY Patient ID: MH-459872 Date of Admission: April 10, 2025 Attending Physician: Dr. Elizabeth Chen, MD (Cardiology) Consulting Physicians: Dr. Robert Martinez, MD (Neurology), Dr. Sarah Williams, MD (Endocrinology) PATIENT INFORMATION Name: John Anderson DOB: 05/22/1968 (57 years old) Gender: Male Address: 45 Maple Street, Apt 3B, Cambridge, MA 02139 Contact: (617) 555-3829 Emergency Contact: Mary Anderson (Wife) - (617) 555-4912 Insurance: BlueCross BlueShield, Policy #BCB-88765432 CHIEF COMPLAINT Patient presented to the Emergency Department with acute chest pain, shortness of breath, and left arm numbness beginning approximately 2 hours prior to arrival. CURRENT MEDICATIONS 1. Metformin 1000mg twice daily (for Type 2 Diabetes, prescribed by Dr. Williams in 2019) 2. Atorvastatin 40mg daily (for Hypercholesterolemia, prescribed by Dr. Chen in 2022) 3. Lisinopril 20mg daily (for Hypertension, prescribed by Dr. Chen in 2022) 4. Aspirin 81mg daily (for cardiovascular health, prescribed by Dr. Chen in 2022) 5. Sertraline 50mg daily (for Depression, prescribed by Dr. Thomas Gordon in 2023) ALLERGIES 1. Penicillin (Severe - Hives, Difficulty Breathing) 2. Shellfish (Moderate - Gastrointestinal distress) PAST MEDICAL HISTORY 1. Type 2 Diabetes Mellitus (Diagnosed 2019 by Dr. Williams) 2. Hypertension (Diagnosed 2020 by Dr. Chen) 3. Hypercholesterolemia (Diagnosed 2020 by Dr. Chen) 4. Depression (Diagnosed 2023 by Dr. Gordon) 5. Left knee arthroscopy (2015, Boston Orthopedic Center, Dr. James Miller) FAMILY HISTORY - Father: Deceased at age 68 from myocardial infarction, had hypertension, type 2 diabetes - Mother: Living, age 82, has hypertension, osteoarthritis - Brother: Age 60, has type 2 diabetes, hypercholesterolemia - Sister: Age 55, no known medical conditions SOCIAL HISTORY Occupation: High school mathematics teacher Tobacco: Former smoker, quit in 2018 (25 pack-year history) Alcohol: Occasional (1-2 drinks per week) Exercise: Walks 20 minutes, 3 times per week Diet: Reports following a "mostly" diabetic diet with occasional non-compliance PHYSICAL EXAMINATION Vital Signs: - BP: 165/95 mmHg - HR: 95 bpm - RR: 22 breaths/min - Temp: 98.6°F (37°C) - O2 Saturation: 94% on room air General: Patient is alert but anxious, in moderate distress Cardiovascular: Irregular rhythm, tachycardia, S3 gallop present, no murmurs Respiratory: Bibasilar crackles, decreased breath sounds at bases bilaterally Neurological: Left arm weakness (4/5 strength), otherwise grossly intact Extremities: No edema, normal peripheral pulses DIAGNOSTIC STUDIES Laboratory: - Troponin I: 2.3 ng/mL (elevated) - CK-MB: 12.5 ng/mL (elevated) - BNP: 450 pg/mL (elevated) - Complete Blood Count: WBC 12,000/μL, Hgb 13.5 g/dL, Plt 230,000/μL - Complete Metabolic Panel: Glucose 185 mg/dL, Cr 1.1 mg/dL, BUN 22 mg/dL - Lipid Panel: Total Chol 210 mg/dL, LDL 130 mg/dL, HDL 35 mg/dL, TG 190 mg/dL - HbA1c: 7.8% Imaging and Other Studies: - ECG: ST-segment elevation in leads II, III, aVF; reciprocal changes in I, aVL - Chest X-ray: Mild pulmonary edema, cardiomegaly - Echocardiogram: EF 40%, inferior wall hypokinesis, moderate mitral regurgitation - Cardiac Catheterization: 90% occlusion of right coronary artery, 70% occlusion of left circumflex artery DIAGNOSIS 1. Acute ST-elevation Myocardial Infarction (STEMI), inferior wall 2. Coronary Artery Disease, multivessel 3. Congestive Heart Failure, acute onset (NYHA Class III) 4. Type 2 Diabetes Mellitus, inadequately controlled 5. Essential Hypertension, inadequately controlled 6. Hyperlipidemia TREATMENT Procedures: 1. Emergency Percutaneous Coronary Intervention (PCI) with drug-eluting stent placement in right coronary artery by Dr. Michael Wilson on April 10, 2025 2. Scheduled PCI for left circumflex artery by Dr. Wilson on April 13, 2025 Medications: 1. Aspirin 325mg daily 2. Clopidogrel 75mg daily 3. Metoprolol succinate 50mg daily 4. Lisinopril 40mg daily (increased from 20mg) 5. Atorvastatin 80mg daily (increased from 40mg) 6. Furosemide 40mg twice daily 7. Metformin continued at 1000mg twice daily 8. Insulin glargine 20 units at bedtime (new) 9. Sertraline continued at 50mg daily HOSPITAL COURSE Patient was admitted through the Emergency Department and taken emergently to the cardiac catheterization lab where he underwent successful PCI with stent placement to the right coronary artery. Post-procedure, the patient was transferred to the Cardiac Care Unit (CCU) for close monitoring. Patient experienced a brief episode of ventricular fibrillation on the first night, which was successfully treated with defibrillation. Cardiology and endocrinology were consulted for management of heart failure and diabetes. Follow-up echocardiogram on April 12 showed improvement in EF to 45%. Patient underwent scheduled PCI of the left circumflex artery on April 13 without complications. DISCHARGE PLAN Discharge Date: April 16, 2025 Discharge Disposition: Home with scheduled home health visits from Memorial Home Health Services Follow-up Appointments: 1. Dr. Elizabeth Chen (Cardiology) - April 23, 2025 at 10:00 AM 2. Dr. Sarah Williams (Endocrinology) - April 25, 2025 at 2:30 PM 3. Cardiac Rehabilitation evaluation - April 30, 2025 at 1:00 PM Patient Education: 1. STEMI and coronary artery disease management 2. Diabetes self-management and glucometer use 3. Heart-healthy diet (consultation with nutritionist completed) 4. Medication management and adherence 5. Warning signs requiring immediate medical attention PROGNOSIS Guarded. Patient has significant coronary artery disease with reduced ejection fraction. Long-term prognosis will depend on medication adherence, lifestyle modifications, and management of comorbidities. ATTESTATION I have personally examined the patient and reviewed all diagnostic studies. This documentation is complete and accurate to the best of my knowledge. Electronically signed by: Elizabeth Chen, MD Cardiology Memorial Hospital Medical Center Date: April 16, 2025 | Time: 14:35