A pleasant 77-year-old smoker with a history of

peripheral vascular disease. She has undergone endograft

stenting of abdominal aortic aneurysm and iliac aneurysm
in 2005. She has a history of hypertension as well as
apparently untreated dyslipidemia.

The patient reported that she had (her) some teeth pulled
(in the) early part of March. She recieved antibiotics
for a couple of days, she began developing significant
diarrhea. This had blood in it. This was associated with
most minimal abdominal cramping. She eventually was
presented to hospital. She was found to have C.diff
infectious colitis, diarrhea was actually improving. The
patient was noted to have minimally elevated troponin.
All initial CK was normal.

An MRI is pending today. Nuclear study shows a poorly

functioning gall-bladder. Ultrasound also suggested
cystic mass in the liver, which is to be evaluated by
MRI. The patient has no prior cardiac history. She
underwent stress testing prior to her endograft repair
and showed normal gated ejection fraction without
evidence of ischemia. An Echocardiogram was performed on
admission which shows normal hypodynamic left ventricular
systolic function without significant valvular disease.

The patient denies any particular chest pain or

breathlessness. She has had some abdominal cramping and
somewhat poor appetite.

Past surgical history is also significant for

hysterectomy.

The patient has no relevant family history or coronary

disease in her early age. She has a history of
hypertension.

The patient is upwards of 2-pack a day smoker. There is

no history of alcohol or other drug use.

There are no known drug allergies.

MEDICATIONS AT HOME: Toprol-XL 300 mg daily, aspirin 81

mg daily, Tarka 2/240 daily, potassium 10 mEq daily, iron
325 mg daily and multivitamin.

REVIEW OF SYSTEMS: Otherwise negative. She has had no

particular fevers or chills. She had no skin breakdowns.
She has had no joint complaints. She has had no urinary
complaints. She has been breathing comfortably. (There
has been) no psychiatric or neurologic problems or
complaints.

PHYSICAL EXAMINATION: Shows an elderly woman in no

distress. Blood pressures is seem to have been running
in the 170-180 range. HEENT is unremarkable. She is
normocephalic, atraumatic. Conjunctivae are noninjected.
Dentition is fair. There is no gross ENT lesions, less
than 6 cm of jugular venous distention. There is no
bruit. Carotid upstrokes are brisk with shotty anterior
and posterior cervical adenopathy. No fixed adenopathy.
Her lungs are clear to auscultation and percussion. Her
heart is regular. There is an S4. There is a short
ejection murmur at the base. There is no holosystolic
murmur. Breasts and pelvic exam are deferred. Abdomen
is soft. There is no tenderness, masses, bruits,
guarding or rebound. There are active bowel sounds.
Soft bilateral femoral bruits. Peripheral pulses are
palpable. There is no edema. Sensation and muscle
strength are grossly intact.

LABORATORY DATA: Troponin is 0.06, 0.25, 0.16.

EKG shows first-degree AV block. Non-specific ST changes.

IMPRESSION:

1. Abnormal troponin. The patient likely has coronary

artery disease; however I suspect that this does not
represent acute coronary syndrome. She has absolutely no
cardiac symptoms, benign ECG. This may just be due to
subendocardial ischemia with LVH and hypodynamic left
ventricle. We would add clonidine to her current medical
regimen. I would favor stress testing to assess
myocardial perfusion.

2. Infectious colitis with workup ongoing.

3. Liver mass, MRI is pending.

4. Electrolyte abnormalities are noted and are being

corrected.
5. Peripheral vascular disease. Patient has a history of
endograft stenting. Her colonoscopy, however, is not
consistent with ischemia.

Thank you very much for allowing me to see this patient.