Lenskyj - cardiac file - Medical Discharge Summary
on 16th. March 2006 at 16:00 -0500
- Note: Dr. Rudiger "Rudy" von Harsdorf at Toronto General Hospital inserted the two drug eluting stents into my RCA heart artery on 15. March 2006. On two subsequent dates he also inserted two stents into my LCx and two more into my RCA cardiac arteries.
=== I abstracted the following from my discharge summary from the
Cardiology C.C.U. Mount Sinai Hospital Toronto, Ontario Canada
Cardiology / CCU Summary
Medical Discharge Summary
This record has been SENT TO MEDICAL RECORDS. The information contained in this record has not been finalized. A final version will be sent to your family doctor.
Last Name: Lenskyj First Name: Adam
DOB: (yyyy/mm/dd) Gender: Male
Family MD: Dr. A. Lofters MSH
Copy List: Dr. Sasson MSH
Attending Physician: Dr. Floras
Admission Date: 2006/3/14 (yyyy/mm/dd) Discharge Date: 2006/03/16 (yyyy/mm/dd)
Most Responsible Diagnosis: Coronary Artery Disease
Past Medical History:
1. DMII - Diagnosed Jan 06 - No medications/No known microvascular complications.
3. Recurrent gallstone pancreatitis - cholecystectomy 2003
Reason for Admission:
Mr. Lenskyj was admitted following a stress echocardiogram strongly positive for diffuse coronary artery disease. He was recently diagnosed with type II diabetes and was meant to begin an excercise program. Stress testing was indicated prior to initiation of this.
Resting echo showed normal left ventricular func tion . Diffuse wall motion abnormalities were induced with exercise (ant, post, apical, septal) suggestive of diffuse disease. But he was asymptomatic during the test. Given the history of silent ischemia, he was admitted to hospital for coronary angiography.
Course in Hospital:
Angiography was performedd on March 15 , 2006 a nd it showed RCA lOO%, LAD 20% and localized LCx 90%. Subsequently , two drug eluted stents were placed in RCA (1OO% - -.> 0%). Plan is for patient to return in 4 - 6 weeks for PCI of LCx.
Mr. Lenskyj developed no complication during and post PTCA . He remains hemodynamically stable . Chest pain free and no evidence of heart failure . Hb stable (130 at discharge) , no Trop rise.
Pertinent Intervention and Lab. Work:
Total chol / HDL 3.2
ECASA 81 mg PO od
Plavix 75 mg PO od
Atorvastatin 40 mg PO qhs
Norvasc 2.5 mg PO od
1. Follow up with Dr. Floras in 4 weeks with repeat stress ECHO.
2. Follow up with family doctor.
Transcribed by: Vicky Chan (CC4)
Transcription Date: 2005/3/16 (yyyy/mm/dd)
Transcription Time: 12:55
Signature: Printed on: 2006/3/16 (yyyy/mm/dd)
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