Allergies
ED Triage Note 10/6
Procedure Note 10/6
Progress Note 10/7
Discharge Summary 10/7
Allergies
BMP/CMP | Coag | ABGs
Basic Metabolic Panel
CBC | Cardiac Panel
Iron | Lipids | Urinalysis
Allergies
+Complete Metabolic Panel
Other
BMP/CMP | Coag | ABGs
IronStudies
CBC | Cardiac Panel
LipidPanel
Iron | Lipids | Urinalysis
Allergies
Other
Urinalysis
Other
Hand X-ray
Interpretation: Ouchie! That hand hurt. But it's probably fine based on this X-ray.
Go to a website to learn more?
Culture and Sensitivity
Campbell Laboratories, LLG Buies Creek, NC 27506
Procedure Note
Procedure: percutaneous coronary intervention (PCI) with placement of a drug-eluting stent (DES) in the left anterior descending (LAD) artery Operators: Dr. Smith (Attending), Dr. Jones (Fellow) Indication: class III angina with 90% proximal LAD stenosis on coronary angiography Procedure Details: Access: Right radial artery was accessed using modified Seldinger technique; 6 Fr sheath inserted. Anticoagulation: Patient was anticoagulated with IV unfractionated heparin. ACT maintained >250 seconds during procedure. Guiding Catheter: A 6 Fr EBU 3.5 guiding catheter was used to engage the left main coronary artery. Lesion Assessment: Angiography demonstrated a 90% stenosis in the proximal LAD. TIMI flow grade II. Wiring: Lesion was crossed with a BMW guidewire without difficulty. Pre-dilation: The lesion was pre-dilated with a 2.5 x 15 mm semi-compliant balloon at 12 atm. Stent Deployment: A 3.0 x 18 mm drug-eluting stent (Xience DES) was deployed at 14 atm across the proximal LAD lesion. Post-dilation: Post-dilation performed with a 3.25 x 12 mm non-compliant balloon at 16 atm for optimal stent expansion. Result: Final angiography demonstrated <10% residual stenosis, no dissection, and TIMI III flow. No complications occurred. Complications: None Estimated Blood Loss: <20 mL Disposition: Patient tolerated the procedure well. Transferred to medicine floor in stable condition. Continue dual antiplatelet therapy with aspirin 81 mg daily and clopidogrel 75 mg daily. Standard post-PCI care per protocol.
ED Triage Note
10/6 0900Patient presents to the emergency department complaining of intermittent chest pain. He reports increased episodes over the past 24 hours, and describes the pain as pressure-like, radiating down his left arm, and not relieved with rest.
Hand X-ray
Interpretation: Ouchie! That hand hurt. But it's probably fine based on this X-ray.
Go to a website to learn more?
Hand X-ray
Interpretation: Ouchie! That hand hurt. But it's probably fine based on this X-ray.
Go to a website to learn more?
Culture and Sensitivity
Campbell Laboratories, LLG Buies Creek, NC 27506
Progress Note
Physical Exam: • General: Alert and oriented ×3, appears anxious and mildly diaphoretic. • Vital Signs: BP 148/92 mmHg, HR 98 bpm, RR 20/min, Temp 98.6°F, SpO₂ 96% on room air. • Cardiovascular: Regular rhythm, no murmurs, rubs, or gallops. Mild chest tenderness on palpation. No peripheral edema. • Respiratory: Clear to auscultation bilaterally, no rales or wheezing. • GI: Soft, non-distended, non-tender. Normal bowel sounds. • Extremities: No cyanosis or clubbing. Peripheral pulses diminished bilaterally. • Neuro: No focal deficits. Cranial nerves II–XII intact Imaging/Procedures: • Electrocardiogram (ECG): ST-segment depression noted in leads V2–V4, consistent with ischemia • Cardiac Biomarkers: Mildly elevated troponin I, trending upward on serial measurements • Coronary Angiography: Revealed critical stenosis (90%) in the proximal left anterior descending (LAD) artery • Intervention: Successful percutaneous coronary intervention (PCI) with placement of a drug-eluting stent (DES) in the LAD Assessment: PL is a 62-year-old male with a history of HTN, T2DM, and HLD presenting with increasing episodes of chest pain consistent with unstable angina requiring urgent PCI and stent placement Plan: • Continue DAPT with Plavix 75mg daily and ASA 81mg per post-PCI protocol • Refer to pharmacist lipid clinic for evaluation of alternative therapies given recent statin intolerance • Reinforce lifestyle counseling including dietary modifications and increasing physical activity as tolerated
Patient Information: Name: PL, Age: 62, Sex: male, chief complaint: chest painHPI: PL presents to the emergency department complaining of intermittent chest pain. He reports increased episodes over the past 24 hours, and describes the pain as pressure-like, radiating down his left arm, and not relieved with rest. PMH: type 2 diabetes, hyperlipidemia, hypertension Medications: • ASA 81mg once daily • Lisinopril 20mg once daily • Amlodipine 10mg once daily • Metformin 1000mg twice daily • Ezetimibe 10mg once daily • Ibuprofen 400mg q6h PRN for pain Allergies: PL states he has allergies to bee venom (anaphylaxis), and statins (simvastatin and atorvastatin caused myalgias) Social history: PL is newly retired and lives with his wife. He reports ~3 alcoholic beverages per week on average and is a current smoker. He denies any illicit substance use. Family history: Mother – T2DM, stroke | Father – HTN, died from MI at 56 ROS: • Constitutional: Denies fever, chills, or recent weight loss. Reports fatigue. • Cardiovascular: Reports chest pain at rest, pressure-like in nature, radiating to left arm. Denies palpitations or syncope • Respiratory: Denies shortness of breath at rest, cough, or wheezing • Gastrointestinal: Denies nausea, vomiting, abdominal pain, or changes in bowel habits. Wears dentures. • Genitourinary: Denies dysuria, hematuria, or urinary frequency • Musculoskeletal: Reports recent history of muscle aches with prior statin use. No current joint pain or swelling. • Neurological: Denies dizziness, weakness, numbness, or headaches • Endocrine: Reports history of type 2 diabetes; denies polyuria or polydipsia • Psychiatric: Denies depression or anxiety • Skin: No rashes or lesions noted • Hematologic/Lymphatic: Denies easy bruising or bleeding
Discharge Summary
Admit Date: 10/6 Discharge Date: 10/7 Procedure: Percutaneous coronary intervention (PCI) with placement of a drug-eluting stent (DES) in the LAD Discharge Medications: START taking: Clopidogrel 75mg once daily CONTINUE taking: Aspirin 81mg once daily Lisinopril 20mg once daily Amlodipine 10mg once daily Metformin 1000mg twice daily Ezetimibe 10mg once daily Ibuprofen 400mg q6h PRN for pain Follow Up Appointment(s): 10/9 Pharmacist Lipid Clinic
PPS 6 Lipid EHR 2025
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Transcript
Allergies
ED Triage Note 10/6
Procedure Note 10/6
Progress Note 10/7
Discharge Summary 10/7
Allergies
BMP/CMP | Coag | ABGs
Basic Metabolic Panel
CBC | Cardiac Panel
Iron | Lipids | Urinalysis
Allergies
+Complete Metabolic Panel
Other
BMP/CMP | Coag | ABGs
IronStudies
CBC | Cardiac Panel
LipidPanel
Iron | Lipids | Urinalysis
Allergies
Other
Urinalysis
Other
Hand X-ray
Interpretation: Ouchie! That hand hurt. But it's probably fine based on this X-ray.
Go to a website to learn more?
Culture and Sensitivity
Campbell Laboratories, LLG Buies Creek, NC 27506
Procedure Note
Procedure: percutaneous coronary intervention (PCI) with placement of a drug-eluting stent (DES) in the left anterior descending (LAD) artery Operators: Dr. Smith (Attending), Dr. Jones (Fellow) Indication: class III angina with 90% proximal LAD stenosis on coronary angiography Procedure Details: Access: Right radial artery was accessed using modified Seldinger technique; 6 Fr sheath inserted. Anticoagulation: Patient was anticoagulated with IV unfractionated heparin. ACT maintained >250 seconds during procedure. Guiding Catheter: A 6 Fr EBU 3.5 guiding catheter was used to engage the left main coronary artery. Lesion Assessment: Angiography demonstrated a 90% stenosis in the proximal LAD. TIMI flow grade II. Wiring: Lesion was crossed with a BMW guidewire without difficulty. Pre-dilation: The lesion was pre-dilated with a 2.5 x 15 mm semi-compliant balloon at 12 atm. Stent Deployment: A 3.0 x 18 mm drug-eluting stent (Xience DES) was deployed at 14 atm across the proximal LAD lesion. Post-dilation: Post-dilation performed with a 3.25 x 12 mm non-compliant balloon at 16 atm for optimal stent expansion. Result: Final angiography demonstrated <10% residual stenosis, no dissection, and TIMI III flow. No complications occurred. Complications: None Estimated Blood Loss: <20 mL Disposition: Patient tolerated the procedure well. Transferred to medicine floor in stable condition. Continue dual antiplatelet therapy with aspirin 81 mg daily and clopidogrel 75 mg daily. Standard post-PCI care per protocol.
ED Triage Note
10/6 0900Patient presents to the emergency department complaining of intermittent chest pain. He reports increased episodes over the past 24 hours, and describes the pain as pressure-like, radiating down his left arm, and not relieved with rest.
Hand X-ray
Interpretation: Ouchie! That hand hurt. But it's probably fine based on this X-ray.
Go to a website to learn more?
Hand X-ray
Interpretation: Ouchie! That hand hurt. But it's probably fine based on this X-ray.
Go to a website to learn more?
Culture and Sensitivity
Campbell Laboratories, LLG Buies Creek, NC 27506
Progress Note
Physical Exam: • General: Alert and oriented ×3, appears anxious and mildly diaphoretic. • Vital Signs: BP 148/92 mmHg, HR 98 bpm, RR 20/min, Temp 98.6°F, SpO₂ 96% on room air. • Cardiovascular: Regular rhythm, no murmurs, rubs, or gallops. Mild chest tenderness on palpation. No peripheral edema. • Respiratory: Clear to auscultation bilaterally, no rales or wheezing. • GI: Soft, non-distended, non-tender. Normal bowel sounds. • Extremities: No cyanosis or clubbing. Peripheral pulses diminished bilaterally. • Neuro: No focal deficits. Cranial nerves II–XII intact Imaging/Procedures: • Electrocardiogram (ECG): ST-segment depression noted in leads V2–V4, consistent with ischemia • Cardiac Biomarkers: Mildly elevated troponin I, trending upward on serial measurements • Coronary Angiography: Revealed critical stenosis (90%) in the proximal left anterior descending (LAD) artery • Intervention: Successful percutaneous coronary intervention (PCI) with placement of a drug-eluting stent (DES) in the LAD Assessment: PL is a 62-year-old male with a history of HTN, T2DM, and HLD presenting with increasing episodes of chest pain consistent with unstable angina requiring urgent PCI and stent placement Plan: • Continue DAPT with Plavix 75mg daily and ASA 81mg per post-PCI protocol • Refer to pharmacist lipid clinic for evaluation of alternative therapies given recent statin intolerance • Reinforce lifestyle counseling including dietary modifications and increasing physical activity as tolerated
Patient Information: Name: PL, Age: 62, Sex: male, chief complaint: chest painHPI: PL presents to the emergency department complaining of intermittent chest pain. He reports increased episodes over the past 24 hours, and describes the pain as pressure-like, radiating down his left arm, and not relieved with rest. PMH: type 2 diabetes, hyperlipidemia, hypertension Medications: • ASA 81mg once daily • Lisinopril 20mg once daily • Amlodipine 10mg once daily • Metformin 1000mg twice daily • Ezetimibe 10mg once daily • Ibuprofen 400mg q6h PRN for pain Allergies: PL states he has allergies to bee venom (anaphylaxis), and statins (simvastatin and atorvastatin caused myalgias) Social history: PL is newly retired and lives with his wife. He reports ~3 alcoholic beverages per week on average and is a current smoker. He denies any illicit substance use. Family history: Mother – T2DM, stroke | Father – HTN, died from MI at 56 ROS: • Constitutional: Denies fever, chills, or recent weight loss. Reports fatigue. • Cardiovascular: Reports chest pain at rest, pressure-like in nature, radiating to left arm. Denies palpitations or syncope • Respiratory: Denies shortness of breath at rest, cough, or wheezing • Gastrointestinal: Denies nausea, vomiting, abdominal pain, or changes in bowel habits. Wears dentures. • Genitourinary: Denies dysuria, hematuria, or urinary frequency • Musculoskeletal: Reports recent history of muscle aches with prior statin use. No current joint pain or swelling. • Neurological: Denies dizziness, weakness, numbness, or headaches • Endocrine: Reports history of type 2 diabetes; denies polyuria or polydipsia • Psychiatric: Denies depression or anxiety • Skin: No rashes or lesions noted • Hematologic/Lymphatic: Denies easy bruising or bleeding
Discharge Summary
Admit Date: 10/6 Discharge Date: 10/7 Procedure: Percutaneous coronary intervention (PCI) with placement of a drug-eluting stent (DES) in the LAD Discharge Medications: START taking: Clopidogrel 75mg once daily CONTINUE taking: Aspirin 81mg once daily Lisinopril 20mg once daily Amlodipine 10mg once daily Metformin 1000mg twice daily Ezetimibe 10mg once daily Ibuprofen 400mg q6h PRN for pain Follow Up Appointment(s): 10/9 Pharmacist Lipid Clinic