Name：Yan Jingyun
Admission date：2008-05-22
Discharge date：2008-5-25
Duration：3 days
Sex：Female
Age：54-year-old
Conditions at admission：
Chief Complaint:Paroxysmal precordial pain for more than 4 years, exacerbates 4 months in duration.
History of present illness:About 4 years ago ,at the time of staying in Canadian,the patient went to hospital because of paroxysmal precordial pain,the coronary angiography undergone there showed high-grade stenosis in proximal left anterior descending(LAD)coronary artery.Thus a stent was placed there.In the past 4 months,she had precordial pain on exertion,the chest pain waned and waxed.
Past history:15-year history of arterial hypertension,deny any history of prior diabetes mellitus.
Physical examination：T:36.2℃ P:68bpm R:16bpm Bp: 130/80mmHg，alert，obesity,no cyanosis，no jugular vein distention，the sound of breath is clear without any dry or moist rales，heart size is normal on
percussion，HR68bpm，regular rhythm，no murmur on auscultation,abdominal distention without tenderness，no hepatomegaly or splenomegaly,shifting dullness negative，no edema exists in the legs。
Admission Diagnosis： Coronary heart disease Unstable angina pectoris Post-PCI
Old myocardial infarction(anterior wall)? Primary hypertension
Hospital course：
The routine diagnostic examinations were taken after adimssion. Serum lipid
：
CHOL4.6mmol/L,TG
5.96mmol/L,HDL-C
0.8mmol/l,LDL-C
1.96mmol/l。Fasting glucose：5.6mmol/L，Postprandial blood sugar：
12.1mmol/L，the chest X-ray examination、echocardiography、nephric function examination、liver function examination and blood routine examination show no obvious abnormality，the coronary angiography shows: no restenosis of the stent in proximal LAD，50％ narrowing of proximal right coronary artery(RCA)，total occlusion at the end of 2nd segment of RCA. An attempt to pass a guidewire across the CTO of RCA failed.
Conditions at discharge：
The patient feels no discomfort，Physical examination：T:36.4℃ P:76bpm R:17bpm Bp: 110/70mmHg，alert，obesity,no cyanosis，no jugular vein distention，the sound of breath is clear without any dry or moist rales，heart size is normal on percussion，HR76bpm，regular rhythm，no murmur on auscultation,abdominal distention without tenderness，no hepatomegaly or splenomegaly,shifting dullness negative，no edema exists in the legs。
Discharge Diagnosis：
Coronary heart disease Unstable angina pectoris Post-PCI
Primary hypertension Diabetes typeII
Medications：
Metoprolol 25mg bid，
Isosorbide Mononitrate 60mg qd，
Felodipine 5mg qd， Aspirin 100mg qd， Telmisartan 40mg qd，
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