DISCHARGE SUMMARY

MIMIC Database Record 237

Date of Birth: 8/6/32
Sex: F
Admission date:7/20/95
Discharge date:7/28/95
Service:C-MED

IDENTIFICATION

Patient is a 62 year old female with a past medical history of inferior wall myocardial infarction in 1988 transferred from Sturdy Hospital for percutaneous transluminal coronary angioplasty for acute therapy of documented inferoposterior myocardial infarction.

HISTORY OF PRESENT ILLNESS

The patient has a past medical history significant for coronary artery disease, hypertension, hypercholesterolemia, status post percutaneous transluminal coronary angioplasty of right coronary artery seven years after suffering an inferior wall myocardial infarction. At the time of that admission the patient presented with acute onset of shortness of breath and arm heaviness. A cardiac catheterization done at that time revealed lesions of the OM1 and a non-critical stenosis of the left anterior descending coronary artery in addition to the high grade right coronary artery lesion which was angioplastied at that time. The ejection fraction was estimated to be 41%. Since that angioplasty, the patient had been managed medically with Cardizem, Toprol, and diuretics. The patient remained asymptomatic until the day of admission when the patient noted sudden onset of dyspnea upon arising from bed which was accompanied with bilateral arm heaviness. The patient rested for a few minutes of her pain and began to develop lightheadedness. The patient denied any nausea, diaphoresis, palpitations or chest pain. The patient presented at the Sturdy Hospital 1 1/2 hours after the onset of symptoms. In the Sturdy Hospital Emergency Room the patient was noted to be in acute respiratory distress with marked pulmonary edema by physical examination and by chest X-ray. The patient was intubated for treatment of respiratory failure. The patient vomited after having a nasogastric tube placed and having just received 80 mEq of potassium chloride via the nasogastric tube. There was a question of aspiration according to the Sturdy Emergency Room physician. The electrocardiogram done in that Emergency Room was consistent with inferior wall myocardial infarction and positive ST elevation in lead V4 on the right sided electrocardiogram. The patient went on to develop ventricular fibrillation arrest in the Sturdy Emergency Room. She was shocked with 300 joules which lead to first a normal sinus rhythm which was then followed by asystole. epinephrine and Atropine were administered intravenously and patient returned to ventricular fibrillation rhythm. Again the patient was shocked, this time at 360 joules and the patient returned to normal sinus rhythm with complete heart block. The patient was placed on Lidocaine and transferred to the Beth Israel Hospital.

PAST MEDICAL HISTORY

1. Coronary artery disease
2. Status post total abdominal hysterectomy
3. Status post cholecystectomy
4. Hypercholesterolemia
5. Hypertension
6. No history of diabetes mellitus
7. Obesity

MEDICATIONS ON ADMISSION

1. Mevacor 20 mg po b.i.d.
2. Diltiazem-CD 180 mg. q. day
3. Toprol-XL 100 mg. po q. day
4. Dyazide

ALLERGIES

NO KNOWN DRUG ALLERGIES

FAMILY HISTORY

Patient's brother died of a myocardial infarction at age 64. Father died of a myocardial infarction at age 50. Mother died of cancer.

SOCIAL HISTORY

The patient works on an assembly line making rings. She lives with the younger of her two sons. The patient denies consumption of alcohol. The patient has a positive smoking history of one pack per day x 30 years which was stopped nine years ago.

PHYSICAL EXAMINATION

In general the patient was a lethargic obese white female as stated on admission. Vital signs included a pulse of 74, blood pressure 120/65, respiratory rate 14, and the patient was afebrile. Head, eyes, ears, nose and throat exam revealed pupil equal and reactive to light, anicteric sclerae and no oropharyngeal lesions. Neck exam revealed 2+ symmetric carotid pulses, no bruits, and no ostensible jugular venous distension. Lungs were clear to auscultation anteriorly. There were moderate inspiratory crackles at the right base, without wheezes. Cardiac exam revealed a regular rate and rhythm, with very distant S1 and S2 and no appreciable murmur. Abdominal exam revealed hypoactive bowel sounds with a soft, nontender, nondistended abdomen without organomegaly. There was a femoral arterial line and a pulmonary artery line in place in the right groin and the dressing was clean and dry and intact. Extremities revealed no clubbing, cyanosis or edema. The pulses were equal and symmetric, 2+/2+.

LABORATORY

Labs. were as follows; white blood cell count 20, hematocrit 40.2, platelets 377. Differential included 92 neutrophils, 1 band, 6 lymphocytes and one mono. Sodium 140, potassium 4.1, BUN 12, creatinine 1.1, glucose 233, calcium 8.2, magnesium 2.2, phosphorus 8.2, CPK 371. Urinalysis at the time revealed on bacteria but was positive for protein and glucose. There were also white blood cells in the urine estimated to be 23 per high powered field. Sputum culture was obtained from a tracheal aspirate and revealed greater than 25 past medical history per high powered field, Gram positive cocci in pairs. Electrocardiogram revealed normal sinus rhythm at 83 beats per minute, with an axis of 0. There is a left atrial abnormality. There are Q waves in leads 3 and AVF. There were T wave inversions in leads 3 and AVF with flattened T waves in 2, V5 and V6. Chest X-ray revealed a left effusion, prominent pulmonary vasculature and increasing opacity at the right lower lung field which is felt to be more likely a soft tissue phenomenon.

HOSPITAL COURSE

Upon admission to the Beth Israel Hospital, the patient was continued on intravenous nitroglycerin, heparin, aspirin and Lopressor. The patient was weaned of the Lidocaine drip. There had been no notable ectopy during her stay in the Cardiac Care Unit. The patient had arrived intubated but was oxygenating and ventilating well and consequently was extubated without difficulty. The patient had several ongoing issues.

1. Cardiovascular. The patient received a cardiac catheterization on 7/20/95 which revealed diffuse disease in the left anterior descending coronary artery (80% stenosis in the mid-region, 60% stenosis in the proximal region). There was a 60% lesion in the proximal left circumflex, 80% stenosis in the right coronary artery which was stented to a residual of 0% stenosis. A 70% lesion in the right coronary artery mid-region was also stented to a residual of 0% stenosis. The patient remained without chest pain after the procedure and was subsequently weaned off her intravenous nitroglycerin and heparin. The patient remained on coumadin with a therapeutic INR of between 3 and 4. The patient tolerated her cardiac rehabilitation well, without complaints of chest pain during ambulation or the stair exercises. Echocardiogram was done on 7/25/95 which revealed a reduced ejection fraction estimated to be 25-30%/ The right ventricular free wall was hypokinetic. There was moderate mitral regurgitation, a dilated left ventricle, global hypokinesis, inferior akinesis, distant inferior wall dyskinesis, and fast motion in the distal anterior, apical and lateral walls. The patient then underwent a submaximal exercise stress test on 7/27/95 which revealed the following. There was a moderate fixed inferior wall, moderate partially reversible anterior wall, severe partially reversible apical wall defects with moderate left ventricular enlargement. Since the patient had been pain free since her transfer to the Cardiology Stepdown unit the patient agreed with the house team that medical management optimization would be the plan for now. The patient would follow up with a maximal exercise stress test in six weeks. The patient would continue with cardiac rehabilitation as an outpatient. The patient was informed that should new symptoms occur that she should notify her doctor for possible re- evaluation of her coronary anatomy and discussion of further interventions, including revascularization via surgery or further angioplasty.

2. Pulmonary. The patient had arrived to the Cardiac Care Unit intubated but subsequently oxygenated and ventilated well and was extubated. The patient maintained good oxygen saturations first on 2 liters nasal cannula and was then subsequently weaned off all oxygen. Although the patient had occasional cough there was no evidence of pneumonia, effusion or pulmonary congestion prior to discharge. The patient had two episodes of hemoptysis of a quarter sized blood clot while on heparin therapy. This was accompanied with normal hematocrit and without any symptoms. This had resolved by the time of discharge.

3. Infectious disease. The patient on admission had an elevated white blood cell count of 20,000. The right based increased density on chest X-ray upon admission was first felt to be a possible aspiration pneumonia. The initial sputum revealed Gram positive cocci. On subsequent X-rays this increased density was felt to possibly be more to do with subcutaneous density than an aspiration. Patient was not treated with antibiotics for this and her white blood cell count subsequently resolved to normal range and patient did not have temperature spikes. The patient did appear to have a urinary tract infection during the admission with a urinalysis on 7/20 revealing 22 white blood cells, 5 red blood cells in the setting of an elevated white blood cell count. The urine culture grew E.coli greater than 100,000 colonies which was resistant to ampicillin. The patient was given one day of intravenous gentamicin therapy and three days of Bactrim po therapy. The patient remained afebrile and denied any symptoms of dysuria, increased urinary frequency or hematuria.

4. Renal. The patient on admission had proteinuria and glycosuria although she had no history of diabetes mellitus. The patient was given regular insulin by sliding scale as needed. Her subsequent glucoses had decreased and appeared to remain within normal limits with a peak of 233, the remaining glucoses remaining in the mid to low 100s. A glucosamine was obtained on 7/22 and was estimated to be 197. Glycosylated hemoglobin A1C was 6.7. Thus it was felt that the patient was not diabetic.

CONDITION ON DISCHARGE

The patient was ambulatory, without chest pain, off all intravenous medications and taking adequate amounts of po. The Patient was off oxygen.

DISCHARGE MEDICATIONS

1. coumadin 4 mg. po on each of the three days after discharge. Afterwards the patient will return to have her PT and INR checked.
2. One aspirin a day
3. Isordil 10 mg. po t.i.d.
4. Norvasc 2.5 mg. po q. day
5. Mevacor 20 mg. po q. day
6. Lisinopril 20 mg. po q. day
7. Ticlid 250 mg. po b.i.d.

The Ticlid, coumadin and Norvasc were to be continued for one month as per the stent protocol. At that time the Ticlid and coumadin will be discontinued. At that time the primary care physician will decided whether Norvasc should be continued.

DISCHARGE STATUS

To home.

PATIENT INSTRUCTIONS

The patient will take coumadin as noted above. The patient will follow up with Dr. ******* on Monday to haver PT and INR evaluated. The patient will return to Beth Israel Hospital for a exercise stress test in six weeks and for follow up with Dr. *******. If the patient develops worsening symptoms the patient is to notify her doctor and be evaluated.

DISCHARGE DIAGNOSIS

1. Inferoposterior myocardial infarction status post angioplasty with two stents in the right coronary artery.
2. Status post inferior wall myocardial infarction in 1988
3. Coronary artery disease
4. Hypercholesterolemia
5. Hypertension
Admission date:8/9/95
Discharge date:9/6/95
Service:Medicine

ADMISSION DIAGNOSES

1. Atherosclerotic occlusive pulmonary artery disease
2. Status post inferior myocardial infarction complicated by pulmonary edema and cardiac arrest
3. Status post percutaneous transluminal coronary angioplasty and stent placement on 7/20/95
4. Left ventricular failure with an ejection fraction of 25%

DISCHARGE DIAGNOSES

Same

PROCEDURE PERFORMED

1. Cardiac catheterization on 8/10/95
2. Coronary artery bypass x 4 - Bypass from the ascending thoracic aorta sequentially to the diagonal and second obtuse marginal with reverse autogenous vein and to the distal right coronary artery with reverse autogenic vein, as well as the left anterior descending coronary artery with the left internal mammary on 8/14/95

HISTORY OF PRESENT ILLNESS

The patient is a 62-year-old obese woman who was referred to the Beth Israel Hospital for cardiac catheterization and the indicated procedures. She suffered an inferior myocardial infarction in 1988 and subsequently underwent angioplasty of the right coronary artery. On 7/20/95, she presented to an outside hospital with a second inferior wall myocardial infarction complicated by congestive failure, pulmonary edema and cardiac arrest. She was successfully resuscitated and underwent angioplasty and stent placement of the proximal right coronary artery. Catheterization at that time also demonstrated severe three- vessel disease. An echocardiogram showed an ejection fraction of 25%. An exercise treadmill thallium performed prior to discharge showed anterior ischemia after 7.5 minutes of exercise. Medical management was maximized; however, she returned to an outside hospital the week prior to admission to unstable angina. A stress test resulted in chest pain and inferior lateral S-T depressions after only two minutes of exercise.

PAST MEDICAL HISTORY

1. Hypertension
2. High cholesterol

SOCIAL HISTORY

Heavy cigarette smoking until approximately seven years ago

FAMILY HISTORY

Coronary artery disease with both her brother and father dying at 60 and 50 years of age, respectively.

PAST SURGICAL HISTORY

1. Total abdominal hysterectomy
2. Cholecystectomy
3. Appendectomy

MEDICATIONS ON ADMISSION

1. Norvasc, 2.5 mg q.d.
2. Aspirin, 325 mg q.d.
3. Isordil, 10 mg t.i.d.
4. Lisinopril, 20 mg q.d.
5. Lopressor, 100 mg b.i.d.
6. Ticlid, 250 mg b.i.d.
7. Lovastatin, 20 mg q.d.
8. Coumadin, which was discontinued earlier in the month

ALLERGIES

NO KNOWN DRUG ALLERGIES.

PHYSICAL EXAMINATION

Physical examination revealed an obese white female in no distress. Vitals - Blood pressure 110-120 in both upper extremities, heart rate 58 and regular, respiratory rate 20 and unlabored. She was afebrile. Her weight today was 270 lbs. Her head and neck exam revealed no jugular venous distention or carotid bruits. Her lungs demonstrated distant breath sounds but no rhonchi or rales. Her heart had a regular rate and rhythm with murmurs, rubs or gallops. Her abdomen was soft with well-healed laparoscopy incisions, as well as a hysterectomy incision. Peripheral pulses were difficult to palpate because of her habitus, however were present and symmetric. There was no evidence of venous disease but, once again, this was difficult to evaluate. Her neurologic exam was nonfocal.

LABORATORY

An admission chest x-ray shows some left lower lobe atelectasis but was otherwise clear. An electroc shows interventricular conduction delay but no acute ischemic changes. There is evidence of old inferior wall myocardial infarction. Admission labs are unremarkable.

HOSPITAL COURSE

A repeat echocardiogram showed an ejection fraction of approximately 25% with moderate mitral regurgitation. This was not evident on ventriculogram at catheterization, however. Left ventricular end diastolic pressure at catheterization was 24 with a wedge of 25. After consultation with the patient, the decision was made to proceed with coronary artery bypass, albeit at slightly increased risk.

On 8/14/95, the patient underwent the procedure described above. All targets were of reasonable caliber and quality, and the conduit was of good quality. She was weaned from bypass without difficulty and there was no evidence of perioperative myocardial injury.

She was extubated on the first postoperative day and transferred to the routine care ward. There, she progressed at a moderately slow pace through postoperative physical rehabilitation. Her postoperative course was complicated by drainage from the lower portion of her sternal incision. The drainage was, however, clear, and gram stain was unremarkable. This was treated with frequent dressing changes and it subsequently healed up and did not require operative intervention. She also developed cellulitis in her left lower extremity that proved very refractory to treatment. After no resolution with IV Ancef, she was switched to Vancomycin. This, in conjunction with continuous elevation, resulted in some improvement; however, the cellulitis persisted. No fluctuance or drainage from the wound was present. An Infectious Disease consultation was obtained and they recommended IV Oxacillin. With IV Oxacillin and bedrest to ensure continuous elevation, the cellulitis slowly resolved. By postoperative day #23, the erythema had resolved and she was approved for discharge. At the time of discharge, she was ambulating well on flat ground and maintaining good hemodynamic response to exercise and adequate arterial oxygen saturations on room air. The erythema was all but gone in her left lower extremity, and her sternal incision was well healed without evidence of drainage.

MEDICATIONS ON DISCHARGE

1. Albuterol, 2 puffs q.d.
2. Ascriptin, 325 mg p.o. q.d.
3. Atenolol, 25 mg p.o. q.d.
4. Niferex, 150 mg p.o. q.d.
5. Colace, 100 mg p.o. b.i.d.
6. Keflex, 500 mg q.i.d. for an additional 10 days

DISPOSITION

The patient is being transferred for additional rehabilitation at the Mariner Healthcare Facility in Sassaquin.

FOLLOW-UP

She will be seen in one month for routine postoperative evaluation.