REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Abnormal EKG and history of coronary artery disease.

HISTORY OF PRESENT ILLNESS: The patient is a pleasant (XX)-year-old Hispanic female who has multiple coronary risk factors and known history of coronary artery disease and had undergone a five-vessel bypass about three years ago. The patient also had a small myocardial infarction prior to that. She was in her usual state of health until about three or four days ago when she started having generalized weakness, feeling dizzy and lightheaded, and easy fatigability.

She had a couple of brief episodes of localized left inframammary chest discomfort, which was lasting for a few minutes. This was not exertional in nature, and this was not pleuritic. There was no radiation and no associated symptoms of shortness of breath, diaphoresis, nausea, vomiting or palpitation. She has not had any nocturnal symptoms. She denied any abdominal pain.

She came to the ER today at 9:30 a.m., and her blood pressure was 156/82, pulse rate 82 per minute. She was afebrile. Respiratory rate was 22 per minute. Pulse oximetry 96%. She was found to be severely anemic and has been admitted to PCU for further evaluation.

Her EKG had abnormalities, and therefore, we have been consulted. Currently, she denies any chest pain. She just feels generally weak.

PAST MEDICAL HISTORY: Hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease status post MI, status post five-vessel CABG. No history of CVA, TIA or thyroid disorder.

PAST SURGICAL HISTORY: CABG about three years ago, hysterectomy, and right kidney surgery.

MEDICATIONS AT HOME: Glucovance, Cozaar 100 mg daily, diltiazem 240 mg daily, Plavix 75 mg daily, and aspirin daily.

ALLERGIES: MULTIPLE DRUG ALLERGIES. SEE CHART.

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: She is married. She is currently not working. She denies any smoking, alcohol or drug abuse.

REVIEW OF SYSTEMS: As mentioned above. Otherwise, no fever, chills, rigors or cough. No sore throat or runny nose. No visual blurring or seizure. No abdominal or genitourinary complaints. No focal weakness of any extremities. She does have diabetic neuropathy with paresthesias of the lower extremities.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 152/86, heart rate 72 per minute, respiratory 18 per minute.
HEENT: Pupils are equally round and reactive to light and accommodation. EOMs intact. Sclerae are anicteric. There is no oropharyngeal congestion.
NECK: Supple. There is no JVD. Bilateral carotids are 2+ with no bruits. No thyromegaly or lymphadenopathy.
LUNGS: Clear to auscultation and percussion.
HEART: S1 and S2 normal. There is no S3, S4, murmurs, rubs, or gallops. Apical impulse is nondisplaced.
CHEST: There is a well-healed scar from a sternotomy.
ABDOMEN: Soft, nontender with no organomegaly. Bowel sounds are present and normal. No pulsatile masses or bruits.
EXTREMITIES: No pedal edema, cyanosis, or clubbing. The bilateral distal pulses are 2+ and symmetric.
NEUROLOGICAL: Grossly nonfocal, motor wise.

LABORATORY DATA: White count 10.8, hemoglobin and hematocrit 7.6 and 22.8, and platelet count 184,000. Protime was 13.2, INR of 1 and APTT 23.4. Sodium 141, potassium 4.8, chloride 108, bicarbonate 24, glucose 132, BUN and creatinine 52 and 1.2, calcium 9.6. CPK 32 and CPK-MB 3.5. Troponin I negative. Urinalysis showed 5 to 10 wbc’s.

EKG done this morning showed normal sinus rhythm with rate 82 per minute. There are diffuse nonspecific ST-T abnormalities, early transition in precordial leads. As compared to prior EKG, ST-T abnormalities are slightly more prominent.

IMPRESSION:
1. This is a (XX)-year-old female with multiple coronary risk factors and known history of coronary artery disease and prior surgical revascularization, who is presenting with severe blood loss anemia secondary to upper gastrointestinal bleed. She is currently hemodynamically stable. It is possible that she may have a bleeding peptic ulcer, and she may have had upper gastrointestinal bleed.
2. Abnormal EKG with nonspecific ST-T abnormalities, which are slightly more prominent than last year. We cannot exclude ischemia, and in view of her history of coronary artery disease and in the presence of severe anemia, which may have precipitated ischemia, she is currently not having any chest pain. She did have some atypical chest pain four or five days ago. Currently, there is no evidence of any decompensated congestive heart failure.
3. History of hypertension.
4. Diabetes mellitus with diabetic neuropathy.
5. History of hyperlipidemia, but currently not on any therapy.
6. Urinary tract infection.

RECOMMENDATIONS:
1. Agree with continuing monitoring on telemetry.
2. Transfuse packed red cells and maintain hemoglobin and hematocrit at around 10 and 30.
3. Would also stop aspirin and Plavix.
4. Agree with proton pump inhibitors.
5. Monitor hemoglobin and hematocrit closely.
6. We will check a fasting lipid profile for risk stratification.
7. We will obtain an echocardiogram to evaluate LV function and assess regional wall motion abnormality.
8. We will obtain serial cardiac enzymes.
9. We will hold diltiazem but will continue Cozaar at lower dose at 50 mg daily, in view of the fact that because of her bleeding, it is possible that she may get hypotensive. Monitor her vital signs closely.
10. Recommend a GI consult.
11. Further recommendations to follow.

Thank you, Dr. Doe, for allowing us to participate in the care of this nice lady.

REFERRING PHYSICIAN: John Doe, MD

HOLTER FINDINGS: The base rhythm was normal sinus with episodic sinus bradycardia and sinus tachycardia with rates ranging between 55 and 130 beats per minute with an average rate of 80 beats per minute. No heart block was observed. No ventricular ectopy was seen. Rare PACs were detected with a total Holter count of 6. No major ST or T wave changes from baseline were observed during monitoring. No symptom diary was returned by the patient for symptom correlation.

CONCLUSIONS:
1. Normal sinus rhythm with sinus arrhythmia and episodic sinus bradycardia and sinus tachycardia.
2. Rare PACs.
3. No symptom diary was returned for symptom correlation.

Sample #2

24-HOUR HOLTER MONITOR REPORT

DATE OF HOLTER: MM/DD/YYYY

REFERRING PHYSICIAN: John Doe, MD

HOLTER FINDINGS: The base rhythm was sinus tachycardia with episodic sinus rhythm with rates ranging between 80 and 150 beats per minute with an average rate of 100 beats per minute. Persistent conduction block of the right bundle type was noted throughout the recording session. No high-grade AV block was seen. There were frequent PVCs detected. There were no runs of ventricular tachycardia observed, but there were runs of ventricular bigeminy noted. No major ST or T wave changes from baseline were seen. No symptom diary was returned by the patient for symptom correlation.

CONCLUSIONS:
1. Sinus tachycardia with sinus rhythm.
2. Right bundle branch block.
3. Frequent PVCs.
4. Frequent PACs.
5. No symptom diary was returned for symptom correlation.

Sample #3

M-MODE, 2-D AND DOPPLER INTERROGATION

DATE OF STUDY: MM/DD/YYYY

PROCEDURE PERFORMED: M-mode, 2-dimensional and Doppler echocardiographic study.

REFERRING PHYSICIAN: John Doe, MD

INDICATIONS: The patient is a (XX)-year-old gentleman with history of dementia and CVA.

FINDINGS:
1. This is a technically limited study; however, there is evidence of left ventricular hypertrophy, and based on limited views, he appears to have preserved systolic function without any obvious regional wall motion abnormalities. However, not all walls are seen clearly. The estimated left ventricular ejection fraction is approximately 55% based on limited views.
2. Normal right ventricular size and preserved function.
3. Right atrial size is within normal limits and there is left atrial enlargement.
4. Aortic root was measured to be of normal caliber.
5. Aortic valve appears to be calcified but mobile. There is no clear evidence of regurgitation and no stenosis across the aortic valve by 2-D and Doppler interrogation. There is trace regurgitation and no stenosis across the mitral valve on 2-D and Doppler interrogation. There is moderate tricuspid regurgitation as well as moderate pulmonic regurgitation.
6. There is evidence of severely elevated pulmonary hypertension. Estimated RV systolic pressure approximately 82 mmHg.
7. No obvious evidence of intracardiac thrombi, vegetation or mass.
8. No evidence of pericardial effusion.

CONCLUSIONS:
1. Technically limited study.
2. Left ventricular hypertrophy with preserved systolic function in limited views without obvious regional wall motion abnormalities; however, not all walls were seen clearly.
3. Based on limited images, it appears that the patient’s systolic function appears to be within normal limits. Ejection fraction visually estimated at approximately 55%.
4. Left atrial enlargement.
5. Moderate tricuspid and pulmonic regurgitation.
6. Severe pulmonary hypertension.
7. There was no evidence of pericardial effusion.

PREOPERATIVE DIAGNOSES:
1. Mitral valve disease, primarily regurgitation.
2. Cardiomyopathy with left ventricular dysfunction.

POSTOPERATIVE DIAGNOSES:
1. Mitral valve disease, primarily regurgitation.
2. Cardiomyopathy with left ventricular dysfunction.

OPERATIONS PERFORMED:
1. Mitral valve repair.
2. Excision of left atrial appendage.
3. Epicardial left ventricular lead implant.

SURGEON: John Doe, MD

SEDATION: General.

SPECIMEN REMOVED: Left atrial appendage.

ESTIMATED BLOOD LOSS: Minimal.

COMPLICATIONS: None.

DESCRIPTION OF OPERATION: The patient was brought to the operating room and positioned supine for mitral valve repair and above procedures. Preoperative intravenous antibiotics were given. Routine preparations were made including a peripheral arterial line, as well as a pulmonary artery catheter demonstrating normal pulmonary artery pressures. Induction of general anesthetic was well tolerated. Oral endotracheal tube was placed without difficulty.

Under sterile prep and drape, a mid sternotomy was performed. The pericardium was opened. The ascending aorta was without palpable plaques. Sinus rhythm was present. Contractility of the right heart was good.

A transesophageal echo probe had been introduced, which demonstrated left ventricular dysfunction with global hypokinesis and an ejection fraction of less than 35%. Examination of the mitral valve demonstrated prolapse of the anterior leaflet with no restriction of the posterior leaflet as previously thought. Regurgitant jet was along the entire area of coaptation, moderate, with a more significant pronounced jet at the A2-A3 junction directed posteriorly.

The patient was placed on cardiopulmonary bypass and cooled to 30 degrees centigrade following a total heparin dose. Antegrade as well as retrograde cold blood cardioplegia technique was employed following application of the aorta cross-clamp. Liberal doses of cardioplegia were delivered thereafter.

Left atrial appendage was excised, no mural thrombus, and sent this specimen to pathology. The excised stump was oversewn flush in a 2-layer fashion. Epicardial bipolar left ventricular lead was screwed in adjacent to the oversewn left atrial appendage stump. A 35 cm lead was taken through the transverse sinus and later tunneled over the pectoral fascia below the left clavicle, exiting the mediastinum to the jugular notch.

Mitral valve was explored through a standard left atrial cardiotomy. Immediately apparent was a billowy, prolapsing anterior leaflet compromising the majority of the surface area of the overall mitral valve. Indeed, a more pronounced prolapse was present at the A2-A3 juncture; however, no chordal fractures were noted.

Testing demonstrated leakage along the entire line of coaptation; however, most pronounced was this previously-described specific area at A2-A3. Anterior leaflet was mildly plicated several millimeters, primarily at the A2-A3 region. A 32 mm annuloplasty ring was sutured in place following careful sizing and suture placement.

Additional saline testing now revealed no regurgitation along the line of coaptation with the exception of the A2-A3 area, which still had slight leakage. Further examination, however, revealed no additional treatment option other than perhaps triangular resection, which I chose not to do for fear of significantly distorting the anterior leaflet.

The left atrial cardiotomy was closed in a 2-layer fashion. Heart was vigorously de-aired, supported on cardiopulmonary bypass until sinus rhythm returned and weaned off cardiopulmonary bypass with no difficulty. Total pump time was 120 minutes. Ischemic cross-clamp time was 90 minutes. Protamine and blood products were given. Hemostasis was obtained.

Re-examination of the transesophageal echo demonstrates trace mitral regurgitation along the entire length of coaptation, other than at A2-A3, which has a 1 to 2+ narrow jet, now directed anteriorly. Pressure was increased to 140 to 150 systolic, with no increase in the mitral regurgitation. Considerable oozing was present, which improved but not stopped with the blood products. Closure of the sternum, however, resulted in hemostasis.

The patient was transferred to the cardiovascular intensive care unit in stable condition.

REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: The patient is a (XX)-year-old female with history of COPD, myelodysplastic syndrome, transfusion dependent, who presented with left-sided chest pain and was admitted for further evaluation.

SOURCE OF INFORMATION: The patient is a poor historian, and history is obtained from nursing staff and previous medical record.

HISTORY OF PRESENT ILLNESS: The patient is a very pleasant (XX)-year-old Hispanic female with multiple comorbidities, including myelodysplastic syndrome resulting for pancytopenia and she is transfusion dependent. She has a history of GI bleeding secondary to AV malformation and history of hypertension for which she is taking multiple medications. She has a history of coronary artery disease, history of abdominal aortic aneurysm; she is status post repair. She has a history of intracranial hemorrhage in the past.

The patient was discharged from the hospital last week after being treated for fluid overload and congestive heart failure. During that time, the patient was treated with diuretics. Today, the patient came for regular blood transfusion, and after blood transfusion, she started to complain of left-sided chest pain and was admitted for further evaluation. Currently, the patient is complaining of chest pain and sharp tenderness localized to the left anterior chest wall. She denies any increasing shortness of breath. She denies any increasing cough, orthopnea or paroxysmal nocturnal dyspnea.

PAST MEDICAL HISTORY: As stated above, includes myelodysplastic syndrome, transfusion dependence, COPD, hypertension, gout, history of GI bleeding secondary to AV malformation, history of intracranial hemorrhage, history of renal insufficiency, history of coronary artery disease, and congestive heart failure. She is status post abdominal aortic aneurysm repair.

MEDICATIONS: List reviewed.

ALLERGIES: PENICILLIN.

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: The patient smokes once in a while. Otherwise, she denies any use of alcohol.

REVIEW OF SYSTEMS: The patient is not a good historian. She denies any increasing shortness of breath, but she coughs once in a while. No orthopnea or paroxysmal nocturnal dyspnea. She is having chest pain as stated in the history of present illness.

PHYSICAL EXAMINATION:
GENERAL: The patient is an elderly lady, in distress secondary to pain localized to the left chest wall. Otherwise, not in cardiorespiratory distress.
VITAL SIGNS: Blood pressure 190/92, pulse rate 82 per minute, respiratory rate 20 per minute, saturating 97% on 2 liters, and temperature 99.2 degrees.
HEENT: Head is atraumatic. Pupils are equal and reactive bilaterally. Pink conjunctivae. Anicteric sclerae. Oropharyngeal examination significant for slight crowding.
NECK: Short.
CHEST: Symmetrical chest expansion. She had some rhonchi, mostly on the right side. She has localized tenderness over the sternum and the left anterior chest wall.
HEART: S1 and S2 are heard.
ABDOMEN: Obese but soft and nontender. No organomegaly.
EXTREMITIES: Did demonstrate edema bilaterally, pitting. No cyanosis or clubbing.
NEUROLOGIC: Alert and oriented x3. No focal deficit.

LABORATORY DATA: Pending.

DIAGNOSTIC DATA: Chest x-ray reviewed. There is no infiltrative process seen. The patient had a CAT scan of the chest done during last admission, which showed minimal effusion on the right side. She has some density localized to the left lower lobe, which was considered to be probable atelectasis. There was cardiomegaly suggested.

ASSESSMENT: The patient is a (XX)-year-old female with multiple comorbidities, including myelodysplastic syndrome, which is transfusion dependent, COPD, history of hypertension for which she has been on multiple medications, coronary artery disease, and congestive heart failure for which she was treated with aggressive diuresis during last admission. The patient now presented for blood transfusion and was admitted with left-sided chest pain. The chest pain seems to be musculoskeletal in origin, but we cannot rule out underlying ischemia. EKG done on presentation did not show any active ST-T change. Otherwise, she had history of chronic obstructive pulmonary disease, hypertension, gout, and prior history of gastrointestinal bleeding and intracranial hemorrhage. She had also history of renal insufficiency.

RECOMMENDATIONS:
1. Continue pain treatment with narcotic.
2. Blood pressure control.
3. Oxygen supplementation.
4. Bronchodilator therapy with DuoNeb.
5. Follow up with WBC and temperature. If she is going up, would start antibiotic therapy. Currently, chest x-ray does not show any significant infiltrate.
6. Would check cardiac enzymes and EKG. The patient would benefit from cardiology evaluation.
7. The patient would continue her regular home medication.
8. We will follow up closely and make appropriate recommendation based on clinical response. Overall, the patient’s prognosis is poor.

PREOPERATIVE DIAGNOSIS: Coronary artery disease.

POSTOPERATIVE DIAGNOSIS: Coronary artery disease.

PROCEDURES PERFORMED:
1.  Endoscopic vein harvesting.
2.  Coronary artery bypass grafting x4 (left internal mammary artery to left anterior descending, saphenous vein graft sequentially to obtuse marginal 1 and obtuse marginal 2, saphenous vein graft to posterior descending artery).

SURGEON:  John Doe, MD

ANESTHESIA:  General.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and placed supine on the operating table. General anesthesia was induced without complication. The patient was prepped and draped in the usual sterile fashion. Preoperative antibiotics had been appropriately completed. The right greater saphenous vein was harvested endoscopically, and the wound was closed with 0 Vicryl and 3-0 Vicryl suture and a 4-0 Monocryl running subcuticular closure. Simultaneously, a median sternotomy was performed and the left internal mammary artery dissected off the anterior chest wall. It was injected with papaverine and placed in the papaverine-soaked sponge.

The pericardium was opened and a cradle raised. The 3-0 Prolene ascending aortic cannulation stitches were placed followed by a 2-0 Ethibond atrial cannulation stitch. After achieving an adequate ACT, a soft-flow aortic cannula was introduced followed by a dual-stage venous cannula. An ascending aortic cardioplegia/root vent was inserted as well as a retrograde cardioplegia cannula into the coronary sinus.

The patient was then placed on cardiopulmonary bypass and the temperature allowed to drift down to 33 degrees. An aortic cross-clamp was applied and 500 mL of cold blood antegrade cardioplegia given with prompt arrest. This was followed by an equivalent amount of retrograde cardioplegia.

Attention was turned to the inferior wall where the posterior descending artery was dissected out and opened longitudinally. The segment of saphenous vein was reversed, spatulated, and anastomosed to it in an end-to-side fashion. The proximal anastomosis was performed to the right side of the ascending aorta and an additional dose of retrograde cardioplegia was given.

Attention was then turned to the lateral wall where the second obtuse marginal branch was dissected out and opened longitudinally. The remaining saphenous vein conduit reversed, spatulated, and anastomosed to it in an end-to-side fashion. A side-to-side transverse anastomosis was constructed between the same segment of saphenous vein and the first obtuse marginal branch. An additional dose of retrograde cardioplegia was given and then the proximal anastomosis was performed to the left side of the ascending aorta.

The patient was then systemically rewarmed. The left internal mammary artery was brought through the lateral pericardium and trimmed and spatulated appropriately. It was anastomosed to the distal left anterior descending coronary artery in an end-to-side fashion. A hot-shot of cardioplegia was given, first retrograde and then antegrade. The aortic cross-clamp was removed, and there was spontaneous return of sinus rhythm. The patient was quickly and easily weaned from cardiopulmonary bypass on a low-dose dopamine. Protamine sulfate was administered without complication, and all cannulas were removed.

Cannulation sites were oversewn with 3-0 Prolene suture. The right atrial appendage cannulation site was reinforced with a heavy silk tie. After assuring adequate hemostasis, pleural as well as mediastinal chest tubes were placed in addition to a ventricular pacing wire.

The pericardium was then closed and the sternum approximated with #6 sternal wires. The wound was irrigated with warm antibiotic solution and closed in layers with 0-Vicryl and 3-0 Vicryl suture and a 4-0 Monocryl running subcuticular closure. Sterile dressings were applied. The patient tolerated the procedure well without any complications. Cross-clamp time was 78 minutes. Cardiopulmonary bypass time was 90 minutes. The patient was transferred intubated in stable condition on a dopamine drip to the cardiovascular ICU. Sponge and needle count was correct at the end of the case.

PREOPERATIVE DIAGNOSES:
1. Coronary artery disease.
2. Left ventricular dysfunction.
3. Ejection fraction, 20%.
4. Aortic stenosis.

POSTOPERATIVE DIAGNOSES:
1. Coronary artery disease.
2. Left ventricular dysfunction.
3. Ejection fraction, 20%.
4. Aortic stenosis.

OPERATION PERFORMED:
1. Coronary artery bypass grafting x1.
2. Aortic valve replacement with a #25 Medtronic Mosaic porcine heart valve.
3. Intraoperative transesophageal echocardiogram.

SURGEON: John Doe, MD

ANESTHESIA: General endotracheal.

COMPLICATIONS: None.

POSTOPERATIVE CONDITION: Stable.

INDICATIONS FOR OPERATION: This is a (XX)-year-old patient who was seen in consultation and was found to have severe aortic stenosis and recommended for aortic valve replacement. In addition, on cardiac catheterization, he was found to have single-vessel coronary artery disease and recommended for LIMA to LAD anastomosis.

DESCRIPTION OF OPERATION: The patient was prepped and draped in the appropriate manner for coronary artery bypass grafting, having undergone general endotracheal anesthetic in addition to a Swan-Ganz catheter placement. A median sternotomy incision was utilized in a standard fashion. The sternum was opened, and the left internal mammary artery was taken out with clips and Bovie cauterization. Papaverine was placed on it and the mammary artery. The vein was harvested from the leg. Then, #4-0 ties and clips were placed in the main branches. A total heparinizing dose was given. We placed the patient on cardiopulmonary bypass support and cooled to 26 degrees.

External cross-clamp was applied. Antegrade and retrograde cold blood cardioplegia was delivered. The left internal mammary artery was then anastomosed to the LAD with coalescent clips. A small bulldog was placed on the mammary artery, and it was affixed to the anterior wall with #6-0 Prolene. We then opened the aorta in a standard fashion, removed the aortic valve and decalcified the annulus. We measured for a #25 Mosaic Medtronic porcine valve. This was then tied down and positioned after appropriate sizing. Sutures were placed through it and tied down into position, closed with a running #4-0 Prolene stitch to the aorta, and the patient was given a warm hot shot of warm retro followed by warm antegrade blood cardioplegia and returned to normal sinus rhythm.

The cross-clamp was removed. Cooley needle was hooked to suction. The patient was re-warmed and weaned from cardiopulmonary bypass support without difficulty. The cannula was removed and reinforced. Mediastinum was irrigated with warm bacitracin solution. Hemostasis was achieved in a standard fashion. The sternum was closed with #6 wire, heavy Dexon suture, running #1, #2-0 and #4-0 silks were utilized.

Dressing and Steri-Strips were applied, and the patient was transferred to the cardiovascular intensive care unit in stable condition.

INDICATION AND HISTORY: This is a (XX)-year-old male with history of craniopharyngioma status post surgery and hypertension, who has been having episodes of lightheadedness and near syncope after surgery. The patient was referred for further evaluation of autonomic function.

DESCRIPTION OF PROCEDURE: The risks, benefits, and alternatives of procedure were explained to patient. All his questions were answered, and he understood and signed informed consent.

The patient was brought to the electrophysiology lab in a fasting, nonsedated state. He was tilted to 70 degrees under continuous blood pressure, heart rate, EKG, and pulse oximeter monitoring. Baseline blood pressure was 122/74 and heart rate was 64.

Immediately after tilt, the blood pressure was 126/94 and heart rate was 88.

During the next five minutes, the blood pressure remained stable at 126/86 and heart rate was 77. Sublingual nitroglycerin was given at this point, immediately after which the blood pressure was 128/87, heart rate was 76.

During the next three minutes, the blood pressure was relatively stable at around 118/96 and heart rate increased to a maximum of 98 beats per minute. During this time, the patient started feeling lightheaded, pale, and nauseated and then passed out, and the blood pressure could not be measured, and he was returned to the supine position immediately. At this point, his heart rate was about 74 beats per minute.

Immediately after returning, the blood pressure was 86/57 and heart rate was 70. The patient tolerated the procedure well, and there were no complications.

CONCLUSION: Positive tilt table test with vasodepressor response.

PLAN: The patient will be observed for a short period and can be discharged home afterwards. The etiology of his lightheaded and presyncopal spells is most likely vasovagal with a large vasodepressor component.

Our recommendation would be to increase fluid intake. Also, we have recommended stopping his antihypertensive gradually over two or three days and then reassess his blood pressure, and if he requires any antihypertensive medication, a beta blocker may be a more suitable option at this point. He should definitely avoid taking any diuretics or vasodilators.

Also, we have prescribed supportive stockings. Also, of concern is that the patient is being replaced with Synthroid and dexamethasone. We are not sure if he requires Florinef also as a part of replacement therapy after his pituitary surgery. This should be evaluated by his endocrinologist.

PREOPERATIVE DIAGNOSIS: Aortic stenosis.

POSTOPERATIVE DIAGNOSIS: Aortic stenosis.

PROCEDURE PERFORMED: Transesophageal echo with Doppler flow imaging, contrast echocardiogram, and conscious sedation, as well as 3-dimensional imaging.

DESCRIPTION OF PROCEDURE: After obtaining informed consent, the patient was brought to the catheterization laboratory where his throat was sprayed with lidocaine spray. He was sedated with a total of 3 mg of Versed and 50 mcg of fentanyl while being constantly monitored by the nurses for heart rate, blood pressure, oxygen saturation, and cardiac rhythm. A transesophageal echo probe was passed to the level of the left atrium, and imaging was done in multiple projections. At one point, the agitated saline was injected for contrast effect. The probe was passed to the stomach for transgastric imaging. Upon removal of the probe, the thoracic aorta was imaged. The patient tolerated the procedure well. There were no apparent complications.

PROCEDURE FINDINGS:

The left atrium was mildly enlarged. There was no mass or thrombus seen in the left atrium or its appendage.

The left ventricle was hypertrophied with normal systolic function. There were no obvious wall motion abnormalities.

The mitral valve leaflets were thickened. There was minimal mitral regurgitation by Doppler echocardiogram.

The aortic valve was trileaflet and the opening was reduced consistent with significant aortic stenosis. It was not very heavily calcified. There was trivial aortic insufficiency. The measurements at the aortic annulus showed a diameter of 29 mm. Two different measurements of the area were 694 and 784.

The sinotubular junction was 23 mm. The sinus of Valsalva was 37 mm.

Right-sided cardiac structures, including the pulmonic and tricuspid valve, were normal. There was mild tricuspid regurgitation.

The interatrial septum was intact. There was no evidence of shunt by either contrast or Doppler echocardiogram.

There was no pericardial effusion.

The thoracic aorta showed mild plaquing but no high-risk protruding atheroma.

IMPRESSION:
1.  Severe aortic stenosis. The annulus appears to be too large for the current technology of transcatheter aortic valve replacements.
2.  Left ventricular hypertrophy with normal systolic function.

CHIEF COMPLAINT: Low heart rate and generalized weakness.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female with history of COPD, active tobacco use, diabetes mellitus, hypertension, and hypothyroidism who was seen at her primary care physician’s office for routine checkup. She was noted to be bradycardic there. An EKG was obtained, which showed AV junctional bradycardia with a heart rate in the mid 30s.

The patient states that over the last few weeks, she has been feeling generalized weakness, lightheaded and dizzy, as well as palpitations. She has had intermittent chest pain for the last few weeks. The last episode of chest pain was about a week ago. It was substernal, not really associated with exertion; although, she has had dyspnea on exertion as well over the last few weeks.

Currently, she denies any chest pain. She denies any shortness of breath. She denies any recent orthopnea or paroxysmal nocturnal dyspnea. She denies any cough. She denies any fevers or chills. She denies any dysuria; although, recently, she has been treated with Keflex for a urinary tract infection.

PAST MEDICAL HISTORY: Chronic obstructive pulmonary disease, active smoker, diabetes mellitus, hypertension, morbid obesity, status post hysterectomy, and chronic kidney disease stage III.

ALLERGIES: Multiple medication allergies, listed in the chart.

MEDICATIONS: ProAir inhaler p.r.n., aspirin 81 mg daily, Lipitor 10 mg daily, buspirone 7.5 mg b.i.d., Coreg 6.25 mg b.i.d., Keflex 500 mg p.o. q.i.d., Lasix 40 mg daily, gemfibrozil 600 mg p.o. b.i.d., NovoLog sliding scale, Lantus 30 units subcu b.i.d., levothyroxine 50 mcg daily, loratadine 10 mg daily, losartan 100 mg daily, Singulair 10 mg at bedtime, fish oil 1000 mg b.i.d., Protonix 40 mg daily, potassium chloride 8 mEq daily, Lyrica 50 mg b.i.d. and 75 mg at bedtime, and trazodone 50 mg daily.

SOCIAL HISTORY: She currently smokes about a pack per day. She denies any alcohol use. She denies any illicit drug use.

FAMILY HISTORY: Positive for cardiomyopathy in her father as well as coronary artery disease in her siblings, as well as diabetes, hypertension, and obesity.

REVIEW OF SYSTEMS: A 10-point review of systems was obtained and was otherwise negative, except as stated in the history of present illness.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 172/90, heart rate 48 and regular, temperature 36.4, respiratory rate 18, and O2 sat 98% on room air.
GENERAL: The patient is alert and oriented x3. She is obese. She is in no apparent distress.
HEENT: Head is normocephalic and atraumatic. Oropharynx is clear. Mucous membranes are moist. Pupils are equal, round, and reactive to light and accommodation.
NECK: Supple. No palpable lymphadenopathy.
HEART: Bradycardic, regular. No obvious murmurs.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Obese, soft, nontender, nondistended. Normal bowel sounds.
SPINE: No spinal tenderness.
EXTREMITIES: No cyanosis, no clubbing. She has trace ankle edema bilaterally.
NEUROLOGIC: No gross focal neurologic deficits.
SKIN: No rashes.
PSYCHIATRIC: Normal thought content and behavior.

LABORATORY DATA: Labs showed a white blood cell count of 11.4, hemoglobin 13.2, hematocrit 41, and platelets 268. Cardiac markers were negative x1. BNP was 846. Chemistry panel showed sodium of 136, potassium 4.8, chloride 104, bicarb 18, BUN 48, creatinine 2.0. Last creatinine was 1.7 last year. GFR is 24. LFTs are normal. Her coags are normal. Her TSH is 1.06.

DIAGNOSTIC DATA: A chest x-ray showed no acute cardiopulmonary abnormalities. A 12-lead EKG done in her primary care physician’s office showed AV junctional bradycardia with a rate in the 30s. Repeat EKG done in the emergency department showed sinus bradycardia with a heart rate about 50. We personally reviewed and interpreted all labs, imaging, and the EKGs.

The medical decision making was of moderate complexity in this patient who is deemed to be at moderate risk for morbidity and mortality.

ASSESSMENT AND PLAN:
The patient is a (XX)-year-old female with history of chronic obstructive pulmonary disease, active tobacco use, diabetes, hypertension, chronic kidney disease stage III, who presents with dyspnea on exertion and symptomatic bradycardia.
1.  Symptomatic bradycardia. We will hold her beta blocker at this time. We will monitor on telemetry. We will give her atropine as needed and transcutaneous pacing as needed and will also check troponins and an echocardiogram and consult Cardiology in the morning for further evaluation and consideration of pacemaker placement.
2.  Dyspnea on exertion and intermittent chest pain the last few weeks. Etiology is unclear. Does not appear to have a COPD exacerbation. She is not anemic. Bradycardia may potentially be causing, not sure; therefore, we will order an echocardiogram and trend troponins. The patient is a high risk for coronary artery disease and will likely need a stress test either as an outpatient or inpatient to rule out coronary artery disease.
3.  Chronic kidney disease stage III to IV. Currently, her creatinine is close to her baseline. We will the dose her medications and avoid nephrotoxins.
4.  Recent urinary tract infection. We will continue Keflex and repeat a urinalysis and Keflex can likely be discontinued if urinalysis is negative.
5.  Diabetes. We will continue the patient on sliding scale insulin.
6.  Hypothyroidism. We will continue levothyroxine.
7.  Hypertension. We will continue her home antihypertensive medications except for Coreg.
8.  Hyperlipidemia. We will continue her statin.
9.  Deep venous thrombosis prophylaxis. Heparin subcu.

CODE STATUS:  Full code.

REASON FOR CONSULTATION: Preoperative cardiovascular risk assessment.

HISTORY OF PRESENT ILLNESS: We were asked by Dr. John Doe to consult regarding cardiovascular risk for dental surgery. The patient is a (XX)-year-old Hispanic woman admitted for oral surgery. She has significant right upper jaw pain. Drainage of an abscess is planned. The patient’s cardiovascular history is notable for longstanding hypertension and stroke. She has atrial fibrillation. There is no known history of coronary artery disease. She denies history of myocardial infarction.

PAST MEDICAL HISTORY: Notable for a history of respiratory failure and tracheostomy placement. She has diabetes, hyperlipidemia, and a depressive disorder. Her cardiovascular history is as noted above.

PAST SURGICAL HISTORY: Notable for left carotid endarterectomy and tracheostomy. She is status post an abdominal hysterectomy as well as a laminectomy.

ALLERGIES: None known.

CURRENT MEDICATIONS: Ampicillin sulbactam 1.5 g IVPB q. 6 h., carvedilol 12.5 mg p.o. b.i.d., cefazolin 2 g IVPB on-call for dental surgery, cetirizine 10 mg daily, cholecalciferol 2000 units daily, clotrimazole topical b.i.d., enoxaparin 40 mg subcu q. 24 hours, escitalopram 10 mg p.o. daily, famotidine 20 mg p.o. q. 12 h., furosemide 40 mg p.o. daily, gabapentin 100 mg p.o. at bedtime, lisinopril 5 mg b.i.d., menthol/zinc oxide topical b.i.d., and multivitamins one p.o. daily.

SOCIAL HISTORY: The patient is single. She never smoked cigarettes. She does not drink alcohol at this time.

FAMILY HISTORY: The patient’s mother had coronary artery disease and died in her 40s. Her father died of cancer. There is no known family history of diabetes or hypertension.

REVIEW OF SYSTEMS: See the history of present illness. A 14-point review of systems was performed. Review of systems is notable for nonproductive cough, dyspnea, and wheezing.

PHYSICAL EXAMINATION:
GENERAL APPEARANCE: No acute distress. The patient is obese. A tracheostomy is in place.
VITAL SIGNS: Temperature 36.6, blood pressure 154/72, pulse 64, respiratory rate 20, SpO2 98%, FiO2 10.0 liters.
HEENT: Pupils are round and reactive to light and accommodation. The oropharynx is clear.
NECK: A tracheostomy is in place. Carotid upstrokes are 2+. The jugular venous pressure is difficult to assess.
LUNGS: There are diffuse rhonchi and wheezes but no rales.
HEART: There is an irregularly irregular rhythm. The first and second heart sounds are of variable intensity. There is a grade 2/6 systolic murmur heard best at the left sternal border. There is no definite third heart sound.
ABDOMEN: Obese. Bowel sounds are present. There is no hepatosplenomegaly.
EXTREMITIES: There is no cyanosis, clubbing or edema.
SKIN: No rash or ecchymosis.

LABORATORY DATA: Glucose 96, sodium 140, potassium 4.0, chloride 100, CO2 of 32, BUN 16, creatinine 0.7, hemoglobin 10.6, platelets 290. PT 16.4, INR 1.5. Hematocrit 34.2.

DIAGNOSTIC DATA: Electrocardiogram performed revealed atrial fibrillation with a controlled ventricular response of 82 beats per minute. There is left axis deviation. A left bundle branch block is present. Cardiac echo performed. The left ventricular size was normal. There was moderate left ventricular systolic dysfunction with a left ventricular ejection fraction of 43%. There was a severe left ventricular diastolic abnormality and paradoxical septal motion consistent with a left bundle branch block. The left atrium was severely enlarged. There was moderate right ventricular hypertrophy and pulmonary hypertension. The right ventricular systolic pressure was 55 mmHg plus right atrial pressure.

IMPRESSION:
1.  The patient’s cardiovascular risk for dental surgery is low to moderate. She does have mild systolic and significant diastolic heart failure. This can be managed medically without much difficulty. There is no history of recent myocardial infarction. Her most significant risk appears to be respiratory. She does have pulmonary hypertension and a history of respiratory failure.
2.  Atrial fibrillation, rate controlled.
3.  Hypertension, poorly controlled.

RECOMMENDATIONS:  We concur with Dr. John Doe, present management with Lovenox as a bridge to surgery while her warfarin has been held. The patient’s lisinopril dose is quite low and will be increased as per orders. The carvedilol will be increased as well.