MIMIC DATABASE RECORD 237 TIMELINE

TIMELINE

MIMIC Database Record 237

Admission date:	20/07/1995
Discharge date:	28/07/1995
Age at admission:	62
Sex:	F

History

Chief Complaint:

Patient was transferred to BI from an outside hospital for her second PTCA in the setting of acute IMI/RVMI.

Present Illness:

Patient w/ hx ischemic heart disease presented to outside hospital early in am of 20/07/1995 w/prolonged chest discomfort and SOB. On arrival at their EW she was in acute respiratory distress with evidence of IMI, CHF, and pulmonary edema. She vomited once after getting KCl. She may have aspirated at this time according to physicians. Her acute course was very complicated. She had a V fib arrest requiring 200 and 300J defibrillation, then transient CHB, then NSR. She was intubated emergently for respiratory failure. She was sent to BIH for further management. Emergency cath done at BIH, revealing elevated filling pressures, and diffuse CAD. She had PTCA x2 with stents placed in proximal and mid RCA w/ good result. She was transferred to the CCU for continuing care.

Past Illnesses:

CAD, S/P PTCA of RCA 7 yrs ago
hypercholesterolemia
HTN
Obesity

Social History

Marital Status:	D
Habits:
Occupation:	secretary (laid off 6 weeks ago)
Tobacco:	Yes
Tobacco Notes:	hx 1 pk/day x30 yrs. Quit 9 yrs ago
Alcohol:	No
Alcohol Notes:
Drug Abuse:
Family History:	Pt's brother died of MI at 64 y.o. Pt's father died of MI at 50 y.o. Mother died of Ca
Allergies:
Past Medications:	Mevacor 20 mg bid Diltiazem CD 180mg qd Toprol - XL 100mg pd Dyazide
Operations:	S/P TAH S/P cholecystectomy
Hospitalizations:

Physical Examination

Date of exam:	20/07/1995
Height:	167.6 cm (66 in)
Weight:	127.3 kg (280 lb)
BSA:	2.31 m²
Pulse:	74
Systolic:	120
Diastolic:	65
Temperature:	37.8° C (100° F) Mode: R
Respiration:	14
General appearance:	Lethargic, obese white female
Skin:
HEENT:	pupils equal, reactive; anicteric sclerae
Neck:	2+ symmetric carotid pulses no bruits, no ostensible JVD, no oropharyngeal lesions
Chest and Lungs:	Moderate inspiratory crackles right base no wheezes
Heart:	RRR, very distant heart sounds S1, S2 OK No murmur heard
Breasts:
Abdomen:	Soft, nontender, nondistended, no organomegaly hypoactive bowel sounds
Genitalia:
Extremities:	Pulses equal and symmetric
Back and Spine:
Nervous System:	pt. intubated A+O x3, moves all extremities
Rectum:

Problem List

Problem	Description	Date Identified	Date Resolved
1	s/p inferolateral and RV MI	20/07/1995
2	V/Fib arrest requiring intubation	20/07/1995
3	Ventricular Ectopy (runs of VT)	20/07/1995	21/07/1995
4	Aspiration during emergency intubation	20/07/1995

20/07/1995

Summary to date:

Patient transferred from outside hospital to BI for PTCA for acute IMI/RVMI. In outside ER, pt experienced resp. distress; pulm. edema seen on CXR. Vomiting -> probable aspiration. V Fib arrest, defibrillated, intubated, stabilized and transferred to BIH. She had cardiac cath, and PTCA x2 with stent placements. Sent to the CCU intubated, for follow-up monitoring and care. On heparin drip, which was increased to 1300 u/hr at 12N because of subtherapeutic PTT.

Upon arrival in CCU she was intubated and sedated. HR 74, BP 120/65, RR 14. Problems include:

1. CAD, s/p PTCA with stents x2.
Plan: Continue IV NTG, heparin, ASA, Lopressor, and supplemental O2. Wean lidocaine drip. Replete K+, Ca++, Mg++ as needed. ECHO in 3-4 days to evaluate LV function.

2. Inf Dis.
WBC elevated to >20,000. CXR suspicious for infiltrate. Tracheal aspirate shows gm + cocci. Urine: WBC present.
Plan: Cover with antibiotics for gm + cocci and for anaerobes.

3. Renal: Patient has glucose and protein in the urine.
Plan: R/O diabetes, check glycosolated hemoglobin.

06:55:00 20/07/1995

Blood Gases

INTUBATED

SP:	ART
TEMP:
RATE:	/10
T_VOL:	1000
PEEP:
O2%:	100
FLO:
PO2:	270
PCO2:	52
PH:	7.21	NO EXTRA CALLS MADE--NURSING UNIT POLICY
TOTCO2:	22
XS:	-7
AADO2:	391
REQO2:	69

Blood Miscellaneous

O2_SAT:
LACTATE:
HGB:	13.1
calcHCT:	39
K+:
Na+:

07:43:00 20/07/1995

Blood Gases

INTUBATED

SP:	ART
TEMP:
RATE:	/16
T_VOL:	1000
PEEP:	0
O2%:	100
FLO:
PO2:	213
PCO2:	35
PH:	7.44
TOTCO2:	25
XS:	0
AADO2:	465
REQO2:	79

Blood Miscellaneous

O2_SAT:
LACTATE:
HGB:	13.8
calcHCT:	41
K+:	3.9
Na+:

07:52:00 20/07/1995

Electrocardiograms

              Intervals             Axes
  Rate     PR-QRS---QT/QTc      P - QRS - T
   83     180 116  444/484      27   -2  -60

Remarks:

Sinus rhythm. Left atrial abnormality. Intraventricular conduction delay. Poor R wave progression with frank Q waves in the lateral leads and inferior leads consistent with infero-apical/lateral myocardial infarction. The inferior myocardial infarction may recent or evolving with T wave inversions in those leads as well as in the lateral leads. Slight ST segment elevation in V4 may represent recent infarction versus aneurysm formation. Q-T interval is prolonged consistent with ischemia, etc. Clinical correlation is suggested. No previous tracing available for comparison.

08:49:00 20/07/1995

Radiology

CORONARY ANGIOGRAPHY
REASON: CAD

Final Report:
EMERGENT CORONARY ANGIOGRAPHY IN CONJUNCTION WITH ANGIOPLASTY INTERVENTION:

THE 62 Y/O FEMALE PATIENT WAS TRANSFERRED TO BETH ISRAEL HOSPITAL FOR EMERGENCY CATHETERIZATION BECAUSE OF AN ACUTE MYOCARDIAL INFARCTION. PROCEDURE WAS PERFORMED BY THE CARDIOLOGY SERVICE. FOR TECHNICAL DETAIL AND RESULTS, SEE CORRESPONDING REPORT. [immediately below]

TECHNICAL NOTE: ISOVUE 76 AS CONTRAST AGENT, 36 MINUTES FLUOROSCOPY.

Cardiac Catheterization

BRIEF HISTORY

The patient is a 62 year old woman with a history an inferior MI in 1988, which was treated with TPA, followed by PTCA of the RCA. At that time, she had an EF of 41%, as well as significant stenoses in her OM1 and D1. She has been treated medically since without significant angina. She presented to an outside hospital at 2:30AM with 1.5 hours of chest pain and dyspnea, was intubated for pulmonary edema, and had VF arrest X 2 and an episode of asystole, treated promptly with atropine with return of sinus rhythm. She had transient complete heart block, and external pacing was secured but not used. EKG revealed an acute inferior and RV MI, and she was transferred by helicopter for primary intervention.

INDICATIONS FOR CATHETERIZATION

Acute Inferior/RV MI

PROCEDURE

Right Heart Catheterization: was performed by percutaneous entry of the right femoral vein, using a 7 French Baim-Turi catheter, advanced to the PCW position through a 8 French introducing sheath. Cardiac output was measured by the Fick method.

Left Heart Catheterization: was performed by percutaneous entry of the right femoral artery, using a 7 French left Judkins catheter, advanced to the ascending aorta through a 8 French introducing sheath.

Coronary Angiography: was performed in multiple projections using a 7 French JL4 and a 8 French AR-1 guiding catheter, with manual contrast injections.

Percutaneous Revascularization: was performed on multiple lesions using balloon angioplasty. In addition stent placement was used. Temporary pacing: was secured by placement of a 7 French bipolar Baim-Turi catheter in the right ventricle.

RESULTS

  **HEMODYNAMICS RESULTS:
BODY SURFACE AREA: 2.10 m2
HEMOGLOBIN: 13.8 gms %
                                               ENTRY                        

  **PRESSURES
PULMONARY ARTERY {s/d/m}                    36/24/28                        
PULMONARY WEDGE {a/v/m}                       -/-/19                        
AORTA {s/d/m}                             145/88/108                        
  **CARDIAC OUTPUT
HEART RATE {beats/min}                            90                        
RHYTHM                                            SR                        
O2 CONS. IND {ml/min/m2}                         125                        
A-V O2 DIFFERENCE {ml/ltr}                        47                        
CARD. OP/IND FICK {l/mn/m2}                  5.6/2.7                        
  **RESISTANCES
PULMONARY VASC. RESISTANCE                       129                        
  **% SATURATION DATA (NL)
PA MAIN                                           75                        
AO                                               100                        
  **ARTERIAL BLOOD GAS
INSPIRED O2 CONCENTR'N                      100% ETT                        
pO2                                              213                        
pCO2                                              35                        
pH                                              7.44                        

                                                FICK                        
  **% SATURATION DATA (FL)
IVC HIGH                                           -                        

OTHER HEMODYNAMIC DATA:      The oxygen consumption was assumed.

  **ARTERIOGRAPHY RESULTS
                                   MORPHOLOGY     % STENOSIS   COLLAT. FROM

  **RIGHT CORONARY
1) PROXIMAL RCA                      DISCRETE          80
2) MID RCA                            TUBULAR       50,70
2A) ACUTE MARGINAL                   DISCRETE          60
3) DISTAL RCA                          NORMAL            
4) R-PDA                             DISCRETE       40-50
4A) R-POST-LAT                         NORMAL            
  **LEFT CORONARY
5) LEFT MAIN                         DISCRETE          20
6) PROXIMAL LAD                      DISCRETE          50
6A) SEPTAL-1                           NORMAL            
7) MID-LAD                            TUBULAR          70
8) DISTAL LAD              DIFFUSELY DISEASED            
9) DIAGONAL-1                          NORMAL            
10) DIAGONAL-2                         NORMAL            
11) INTERMEDIUS                      DISCRETE       60-70
12) PROXIMAL CX                      DISCRETE       60,50
13) MID CX                             NORMAL            
14) OBTUSE MARGINAL-1                  NORMAL            
15) OBTUSE MARGINAL-2                  NORMAL            

  **PTCA RESULTS
                          PROX RCA  MID RCA                                    

  **BASELINE
STENOSIS PRE-PTCA               80       70                                    
  **TECHNIQUE
GUIDING CATH                8 F HS  8 F JR4                                    
GUIDEWIRES                0.014 HT 0.014 ST                                    
INITIAL BALLOON (mm)           3.5      3.5                                    
FINAL BALLOON (mm)             3.5      3.5                                    
# INFLATIONS                     6        4                                    
MAX PRESSURE (PSI)             300      300                                    
  **RESULT
STENOSIS POST-PTCA               0        0                                    
DISSECTION (0-4)                 0        0                                    
SUCCESS? (Y/N)                   Y        Y                                    
NUMBER OF BALLOONS USED:         4

PTCA COMMENTS

Preliminary angiography disclosed an 80% stenosis in the proximal RCA, with haziness consistent with residual thrombus. There was a long 70% mid-RCA stenosis as well. The vessel had normal flow. The proximal stenosis was crossed easily with a 0.014 HTF wire, via the 8F JR4 guide, which provided good support. The stenosis was dilated with a 3.5 Predator, and after initially good result, there was noted to be considerable recoil and a 1+ dissection limited to the proximal RCA. It was therefore decided to place a stent. However, because there would be impedance to runoff, the mid-RCA lesion was first addressed. It was predilated with the 3.5 Predator at low pressure. A 3.5 Palmaz Schatz coronary stent was deployed and post dilated at high pressure with a 3.5 Titan. A 3.5 Palmaz Schatz stent was then deployed in the proximal vessel and postdialted similarly.

TECHNICAL FACTORS

Total time (Lidocaine to test complete) = 1 hour 54 minutes.
Arterial time = 1 hour 47 minutes.
Fluoro time = 36 minutes.

Contrast:	Isovue, vol 330 ml, Indications - Hemodynamic
Anesthesia:	1% Lidocaine subq.
Anticoagulation:	Heparin 17,500 units IV
Other medication:	Lidocaine 1-3 mg/min iv infusion TNG 140-240 mcg/min IV infusion Lopressor 2.5 mg IV
Balloons used:	3.5 14, PREDATOR 3.5 5, SCHATZ-PALMAZ STENT 3.5 5, SCHATZ-PALMAZ STENT 3.5 14, TITAN 18, 18MM

COMMENTS

1. Coronary angiography revealed three vessel CAD in this right dominant system. The RCA had an ulcerated plaque with thrombus proximally with an 80% stenosis, which was considered the culprit lesion. The mid RCA was diffusely diseased and moderate stenoses were seen in the proximal acute marginal and PDA. The LMCA had minimal disease. The proximal LAD had diffuse disease with a 50-60% stenosis before and after the first septal branch. A long tubular 70% stenosis was present in its mid segment and distally there was mild diffuse disease. The diagonal branches were small and a very large intermedius had serial 60-70% proximal and mid stenoses. The Cx had a 60% proximal stenosis.
2. Resting hemodynamics revealed elevated mean PCWP=19mmHg and PA diastolic pressure =24mmHg with borderline normal cardiac index and normal pulmonary vascular resistance.
3. Left ventriculography was not performed.
4. Stenting was successfully performed on stenoses in the proxiaml and mid RCA (see PTCA comments).

FINAL DIAGNOSIS

1. Three vessel coronary artery disease.
2. Moderate diastolic and systolic dysfunction.
3. Acute inferior myocardial infarction managed by primary PTCA and Palmaz-Schatz stent placement.

09:30:00 20/07/1995

Basic Coagulation

PT:
PT_MEAN:
PTT:
PTT_MEA:
PLT_SMR:
PLT_COU:	337
INR(PT):

Complete Blood Count

WBC:	20.5	1 DOUBLE CHECKED
RBC:	4.63
HGB:	13.9
HCT:	40.2
MCV:	87
MCH:	29.9
MCHC:	34.5
RDW:	14.1

Differential

NEU:	92
BAN:	1
LYM:	6
MON:	1
EOS:	0
BAS:	0
ATY:	0
MET:	0
MYE:	0
PRO:
YOU:
BLA:
HYP:
RCS:
OTH:

Red Cell Morphology

HYPOCHR:	NORMAL
ANISOCY:	OCCASI	1 OCCASIONAL
POIKILO:	OCCASI	1 OCCASIONAL
MACROCY:	NORMAL
MICROCY:	NORMAL
POLYCHR:	NORMAL
STIPPLE:
SPHEROC:
OVALOCY:
SCHISTO:
TARGET:
BURR:
FRAGMEN:
ACANTHO:
TEARDRO:

09:46:00 20/07/1995

Chemistry

Protein:
Albumin:
Glob:
Ca:	8.2
PO4:	3.2
Mg:	2.2
UricAcd:
Iron:
TotChol:

CPK Isoenzymes

CPK-MB:
CALC'D:
CPK:	371
CK-MB:	43
MB_INDX:	11.6

Enzymes and Bilirubin

ALT/GPT:
AST/GOT:
LD:
CK:	371
AlkPhos:
Amylase:
TotBili:
DBil:
IBil:

Renal and Glucose

Glucose:	233
BUN:	12
Creat:	1.1
Na:	140
K:	4.1
Cl:	104
TCO2:	23
A_Gap:	17

10:53:00 20/07/1995

Blood Gases

INTUBATED; IMV

SP:	ART
TEMP:	37.8
RATE:	12/12
T_VOL:	1000
PEEP:
O2%:	50
FLO:
PO2:	163
PCO2:	33
PH:	7.43
TOTCO2:	23
XS:	0
AADO2:
REQO2:

Blood Miscellaneous

O2_SAT:	98
LACTATE:
HGB:
calcHCT:
K+:
Na+:

10:57:00 20/07/1995

Blood Miscellaneous

O2_SAT:	70	1 MIXED VENOUS
LACTATE:
HGB:
calcHCT:
K+:
Na+:

11:00:00 20/07/1995

Continuous Medication Drips

Heparin (25000 u in 250 cc)	12 cc/hour
Lidocaine (2 g in 250 cc)	7.5 cc/hour
Nitroglycerine (50 mg in 250 cc)	9 cc/hour

11:21:00 20/07/1995

Radiology

CHEST (PORTABLE AP)
REASON: 62 yo f s/p MI complicated by vfib arrest, s/p PTCA this Am. r/o chf, r/o aspiration.

Final Report:
HISTORY: S/P MI. S/P PTCA THIS A.M.
FINDINGS: WE HAVE NO RECORD OF RECENT PRIOR BIH CHEST RADIOGRAPH FOR COMPARISON. AP SUPINE CHEST. THE HEART APPEARS ENLARGED. THERE IS UPPER ZONE REDISTRIBUTION AND INTERSTITIAL EDEMA, WITH AREAS OF MORE CONFLUENT AIR SPACE DISEASE IN THE RIGHT LOWER ZONE. THIS COULD REPRESENT ATYPICAL CHF, BUT ASPIRATION CANNOT BE EXCLUDED. ETT TIP IS APPROXIMATELY 2 CM ABOVE THE CARINA. NG TUBE TIP IS BELOW THE DIAPHRAGM. TIP OF SWAN-GANZ CATHETER, WHICH APPEARS TO HAVE BEEN INTRODUCED VIA FEMORAL APPROACH, LIES IN THE RIGHT MAIN PULMONARY ARTERY.

IMPRESSION: MODERATE CHF. SUPERIMPOSED CONSOLIDATION CANNOT BE EXCLUDED IN THE RIGHT MID ZONE.

11:54:00 20/07/1995

Blood Gases

INTUBATED

SP:	ART
TEMP:	37.8
RATE:	0/20
T_VOL:
PEEP:
O2%:
FLO:
PO2:	90
PCO2:	42
PH:	7.37
TOTCO2:	25
XS:	0
AADO2:
REQO2:

Blood Miscellaneous

O2_SAT:	96
LACTATE:
HGB:
calcHCT:
K+:
Na+:

12:57:00 20/07/1995

Blood Gases

NOT INTUBATED; NEBULIZER

SP:	ART
TEMP:	37.2
RATE:	/20
T_VOL:
PEEP:
O2%:	100
FLO:
PO2:	147
PCO2:	42
PH:	7.39
TOTCO2:	26
XS:	0
AADO2:	524
REQO2:	88

Blood Miscellaneous

O2_SAT:	98
LACTATE:
HGB:
calcHCT:
K+:
Na+:

13:00:00 20/07/1995

Progress Notes

Patient extubated without incident.

16:00:00 20/07/1995

Continuous Medication Drips

Nitroglycerine (50 mg in 250 cc)

6 cc/hour

17:27:00 20/07/1995

Basic Coagulation

PT:
PT_MEAN:
PTT:	90.7	1 DOUBLE CHECKED
PTT_MEA:	27.5
PLT_SMR:
PLT_COU:	308
INR(PT):

Complete Blood Count

WBC:	17.4
RBC:	4.35
HGB:	13.1
HCT:	38
MCV:	88
MCH:	30
MCHC:	34.3
RDW:	14.2

CPK Isoenzymes

CPK-MB:
CALC'D:
CPK:	859
CK-MB:	61
MB_INDX:	7.1

Enzymes and Bilirubin

ALT/GPT:
AST/GOT:
LD:
CK:	859
AlkPhos:
Amylase:
TotBili:
DBil:
IBil:

Renal and Glucose

Glucose:	152
BUN:	13
Creat:	0.9
Na:	145
K:	3.6
Cl:	108
TCO2:	26
A_Gap:	15

17:30:00 20/07/1995

Blood Gases

NEBULIZER

SP:	ART
TEMP:	38.1
RATE:
T_VOL:
PEEP:
O2%:	50
FLO:
PO2:	119
PCO2:	46
PH:	7.36
TOTCO2:	27
XS:	0
AADO2:
REQO2:

BLOOD:	SM
NITRITE:	NEG
PROTEIN:	NEG
GLUCOSE:	NEG
KETONE:	NEG
BILIRUBIN:	NEG
UROBILINOGEN:	.2
PH:	5.0

SPECIMEN_TYPE:	CATHET	1 CATHETER
COLOR:	YELLOW
APPEARANCE:	CLEAR
SPECIFIC_GRAVITY:	1.019

PT:	12.1
PT_MEAN:	11.1
PTT:	53.4	1 DOUBLE CHECKED
PTT_MEA:	27.5
PLT_SMR:
PLT_COU:
INR(PT):	1.2

SP:	ART
TEMP:	37.7
RATE:
T_VOL:
PEEP:
O2%:	50
FLO:
PO2:	148
PCO2:	53
PH:	7.38
TOTCO2:	33
XS:	4
AADO2:
REQO2:

Lidocaine (2 g in 250 cc)	discontinued
Nitroglycerine (50 mg in 250 cc)	12 cc/hour

PT:	12.8
PT_MEAN:	11.1
PTT:	64.9	1 DOUBLE CHECKED
PTT_MEA:	27.5
PLT_SMR:
PLT_COU:	250
INR(PT):	1.3

WBC:	12.3
RBC:	3.95
HGB:	11.8
HCT:	34.8
MCV:	88
MCH:	29.8
MCHC:	33.9
RDW:	14.1

KCl	40	meq	po
Lopressor	50	mg	po
ASA	325	mg	po	qd
Isordil	10	mg	po
Mevacor	20	mg	po
Colace	100	mg	po	bid
Axid	150	mg	po	bid

SP:	ART
TEMP:	37.5
RATE:
T_VOL:
PEEP:
O2%:
FLO:	6
PO2:	131
PCO2:	43
PH:	7.42
TOTCO2:	29
XS:	2
AADO2:
REQO2:

Ticlid	250	mg	po	bid
Lopressor	50	mg	po
ASA	325	mg	po
Mevacor	20	mg	po
Colace	100	mg	po	bid
Axid	150	mg	po	bid

KCl	40	meq	iv	x1 over 2 hrs
Lasix	40	mg	ivp	x1

PT:	12.1	1 HEMOLYZED, MODERATELY
PT_MEAN:	11.1
PTT:	46.4
PTT_MEA:	27.5
PLT_SMR:
PLT_COU:	196
INR(PT):	1.2

WBC:	10.4
RBC:	3.66
HGB:	10.9
HCT:	32.6
MCV:	89
MCH:	29.9
MCHC:	33.5
RDW:	14.2

NEU:	74.2
BAN:	0
LYM:	19.8
MON:	4.9
EOS:	0.4
BAS:	0.7
ATY:
MET:
MYE:
PRO:
YOU:
BLA:
HYP:
RCS:
OTH:

Heparin (25000 u in 250 cc)	15 cc/hour
Nitroglycerine (50 mg in 250 cc)	discontinued

TIMELINE