This is one of several admission for this 65 year old African-American male with a several year history of atheroscleratic coronary arterial disease statuspost MI and coronary artery bypass grafting three year ago the evening of admission she experience chest pain beginning about one hours prior through presentation to the hospital  se also experienced diaforesis and shortness of breathe he take three nitroglycerine sublingual and when she did not obtained release he present to the emergency department.



On presentation to the emergency department his vital sign were table with a blood pressure of 150 over 80 and he was comfort and in no ac ute distress  skin revealed well healed thoracotomy scare as well saphenous vain harvest scar  Fundus revealed hypertension changes but no hemorhage are exudates. Lung were clear the heart showed regular rate in rhythm but with a pericardial rib at midsystole hear best or the base there was know chest valve tenderness he had trace oedema in both lower extremity to the niece  digital pulses was in fact.



SMA 20 on admission revealed creatin to be mildly elevated at 1.9 BUN 21 Initial CPK was 45 with 100 % MM fraction repeat CPK was unchanged electrolyte were with in normal limits the sodium 131 in potassium 4.0. Digoxin level return elevated at 2.5. CBC was with in normal limits EKG revealed Q waves in the inferior leads but no new changes to suggest an a cute event.

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