DISCHARGE DIAGNOSIS: Acute inferior wall, myocardial infarction, status post, cardio catheterization with right coronary artery, distal branch 100% occlusion status post, (___PTCA) and (___) of same. Patient tolerated the procedure quite well, has had an uneventful post procedure time in the (step bound) unit post catheterization. His cardiac enzymes #2 and #3 had elevations on the (___treponema) and the (___) bands. He had also elevation of the white blood cell count, which is something quite normal in the face of acute myocardial infarction, (acute ischemic) event. His (___) elevations persisted all through the first 24 hours, and now he is evolving into a completed myocardial infarction with Q waves presentation inferior and laterally leads.
PLAN: He was put on Lipitor 80 mg with a total cholesterol of 190, triglycerides around (160___70). LDL around 122 and a HDL of 40, and consequently was given Lipitor as I said, 80 mg 1 p.o. q.d., aspirin 325 mg once daily, (Plavix) 75 mg once daily, (metoprolol) 25 mg one p.o. b.i.d. twice daily,and (___) which is 2.5 mg once daily. Consequently, he is on the (classical) post myocardial infarction medications which include (beta-blocker), Ace inhibitor, anticoagulation including Plavix and aspirin, and (hypolipidemic) agent starting in maximum amount. We are (maximizing) the therapy consequently, his blood pressure has been always on the low side, post procedure. Remembering that this patient has a history of hypertension as the only risk factor, for him besides a severe family history where at least one element of his family died at age very early, for coronary artery disease. Will feel very comfortable in allowing him to go home today, after evaluation by the cardiologist, and we will (followup) on the situation in another 4 days, (___) to repeat the liver enzymes to evaluate the possible intoxication by (starting) and evaluate the repeat EKG to complete the workup, which is required in situations like this. He will not be able to fly back to Canada, within the next 15 days, but he is going back by car, and because of that, we will make sure that we will give him clearance to return by car within the next 7 days, that's why he is going to be seeing me at the clinic in 4 days, and will see the cardiologist the day after. ___ [NAME] is going to need complete metabolic panel, a CBC, and a repeat EKG, at my office in 4 days