DISCHARGE SUMMARIES

Discharge Summary  
Discharge Summary #2 

DISCHARGE SUMMARY 

PROCEDURE PERFORMED:  
1.  Cardiac catheterization.
2.  Stent to the marginal vein graft.

HISTORY OF PRESENT ILLNESS:  This is a patient with known coronary artery disease who presented with chest pain.  History is remarkable for hypertension, reformed tobacco abuse, chronic obstructive pulmonary disease and a history of sleep apnea.  He was transferred from XYZ Hospital in stable condition.

The patient's cardiac history dates back to 1997 when he suffered a myocardial infarction, followed by a five-vessel coronary artery bypass graft.  He has done well since then, with no complaints of chest pain until recently.

On the day prior to admission, he presented to XYZ Hospital with sudden onset of shortness of breath and chills.  Chest x-ray showed a left lower lobe infiltrate.  Subsequent work-up included a positive D-dimer.  Chest CT scan showed no evidence of pulmonary embolus.  He was treated with antibiotics and steroids and was admitted.  The following morning, he had an episode of chest pain associated with electrocardiogram changes.  He was transferred to the ICU and IV nitroglycerin was added.  Given his cardiac history and these recent events, he was referred to Dr. Elmer Fudd for further evaluation and management.  

LABORATORY DATA:  WBC 16.8 (7.4 on discharge), hemoglobin 12.7, hematocrit 37, MCV 90, platelet count 174,000.  Serum sodium 138, potassium 4.7, glucose 191, BUN 22, creatinine 1.0.  Fasting cholesterol 151, HDL 54, LDL 82, triglycerides 77.  Serial CPKs negative.  Urinalysis showed specific gravity 1.011, pH 5.5, no protein, no glucose, large hemoglobin, no leukocyte esterase, no nitrites, 16 red blood cells, 0-4 white blood cells.

RADIOGRAPHIC/ACCESSORY DATA:  Electrocardiogram showed sinus rhythm with a rate of 63 and without evidence of acute changes.

HOSPITAL COURSE AND TREATMENT:  The patient was admitted to the CCU with IV heparin and nitroglycerin.  Myocardial infarction was ruled out with serial CPKs.  Given his cardiac history and recurrent chest pain, he underwent an uncomplicated cardiac catheterization by Dr. Elmer Fudd on July 24.  This revealed well-preserved left ventricular function but mild anterior hypokinesis.  Ejection fraction was 60%.  The left anterior descending had a 50% occlusion in the middle segment and a 75% occlusion in the distal segment.  The left circumflex artery had 100% occlusion.  The first marginal branch had 100% occlusion.  The second marginal branch had 100% occlusion.  The right coronary artery had 100% occlusion.  There were four grafts identified.  The saphenous vein graft to the right coronary artery was patent.  The sequential graft to the left anterior descending then to the first marginal and then to the second marginal was totally occluded at the ostium of the left anterior descending and had an 80% occlusion at the junction of the first marginal.  The second marginal graft was patent.  The lesion at the junction of the marginal artery and the saphenous vein graft was successfully stented utilizing a 13/3.0 stent.  The residual stenosis was reduced to less than 10%.

The patient tolerated the procedure well.  His activity level was progressed and well tolerated.  There were no further problems associated with chest pain or arrhythmia. 

The patient initially presented to XYZ Hospital with shortness of breath and chills.  Subsequent chest x-ray showed a left lower lobe pneumonia.  Dr. Daffy Duck was consulted for a Pulmonary Medicine evaluation.  Medical therapy was continued with antibiotics.  Advair and Combivent were added and well tolerated.  The steroids were tapered.  His activity level was progressed and well tolerated.  His oxygenation slowly improved and the oxygen was weaned off.  Pulmonary function tests were done and showed an FVC of 47% of the predicted and FEV1 33% of predicted.  His condition continued to improve.  He has a history of sleep apnea and Dr. Fudd recommended a repeat sleep study.  However, this test could not be performed due to scheduling difficulties.

With continued progress, the patient was able to be discharged on July 30, 2002 with medications listed below.

DISCHARGE MEDICATIONS:
1.  Plavix 75 mg q.d. for 30 days
2.  Enteric-coated aspirin 325 mg q.d.
3.  Zestril 20 mg q.d.4.                
4.  Prednisone taper.
5.  Advair one puff b.i.d.
6.  Combivent two puffs q.i.d.
7.  Folic acid q.d.
8.  Tagamet as directed.
9.  Etodolac.

IMPRESSION:  Per Dr. Fudd.
1.  Chest pain.
2.  Normal left ventricular function.
3.  Three-vessel coronary artery disease with four of four grafts patent after successful stenting of the marginal artery/graft junction.
4.  Left lower lobe pneumonia. 
5.  Bronchospastic lung disease.
6.  Reformed tobacco abuse.
7.   Emphysema.
8.  History of sleep apnea.
9.  Advanced rheumatoid arthritis.
10.  Hypertension.
11.  Hyperlipidemia.
12.   Gastroesophageal reflux disease.

PLAN:  Per Dr. Fudd.  The patient will be discharged to the followup care of Dr. Duck to include an office visit within the following two weeks.  He is to schedule an appointment to see Dr. Tweety Bird in two months for repeat pulmonary function tests and a sleep study.  A stress test is recommended in three months and then every year thereafter.  He should continue the medications listed above.  He was instructed to stop the Serevent.  He may resume his usual activities as tolerated.  He was advised to report recurrent symptoms to his primary physician or to our office.

DISCHARGE SUMMARY #2 
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HISTORY OF PRESENT ILLNESS:  This is a 77-year-old male with no prior cardiac history who is now referred for cardiac catheterization to evaluate chest pain.  

The patient gives a several month history of left anterior chest and throat "burning and tightness," occurring with exertion, associated with mild shortness of breath and improving with rest after approximately five minutes.  A SPECT-thallium performed on June 11, 2002 revealed no evidence of frank ischemia.  Left ventricular ejection fraction was 58%.  He has had persistent symptoms, although he describes some improvement on atenolol.  He denies radiation of the pain, nausea, vomiting, diaphoresis, palpitations, syncope or near syncope.  He gives no history of orthopnea or paroxysmal nocturnal dyspnea.  

PAST MEDICAL HISTORY: 
1.  Hypertension.
2.  Hypercholesterolemia.
3.  Prostate cancer.
4.  Status post prostatectomy.
5.  Status post vein stripping.
6.  Arthritis.

MEDICATIONS:  
1.  Celebrex 200 mg p.o. q.d.
2.  Amitriptyline 25 mg p.o. q.h.s.
3.  Lipitor 10 mg p.o. q.h.s.
4.  Atenolol 25 mg p.o. q.d.
5.  Aspirin 325 mg p.o q.d.

ALLERGIES:  No known drug allergies.  

FAMILY HISTORY:  Positive for coronary artery disease, brother had bypass surgery at uncertain age, sister underwent stenting in her 70s. 

SOCIAL HISTORY:  The patient is married.  He is a retired furniture salesman.  He denies tobacco or alcohol abuse.

REVIEW OF SYSTEMS:  Describes occasional lower extremity edema, which has improved with support hose.  He is also hard of hearing.

PHYSICAL EXAMINATION:  Alert and oriented, comfortable-appearing male.  HEENT:  Pupils equal, round and reactive to light.  NECK:  Supple.  No adenopathy or carotid bruits.  HEART:  Regular rate and rhythm.  S1 and S2.  No murmurs, gallops or rubs.  PMI normal.  Negative jugular venous distention.  LUNGS:  Clear.  ABDOMEN:  Soft, nontender.  Positive bowel sounds times four.  EXTREMITIES:  Warm, without edema.  Pulses 2+ throughout except for trace to 1+ right pedal and trace posterior tibial pulses.  No femoral bruits heard.

IMPRESSION:  Angina pectoris, despite medical therapy.

PLAN:  Cardiac catheterization with further management based on findings.  Preprocedure teaching has been done.  The patient indicates his understanding and consents.

HOSPITAL COURSE AND TREATMENT:  Cardiac catheterization was performed on August 2, 2002 revealing a normal left ventricle.  Coronary angiography revealed a normal left main; 70-90% stenoses of the proximal, mid and distal left anterior descending; 50% stenosis of the mid left circumflex with 99% stenosis of the mid obtuse marginal branch; and 90% stenoses of the proximal and mid right coronary artery.  The patient tolerated the procedure without complication.  His postprocedure course was stable.  Coronary artery bypass graft surgery was recommended to the patient.  Consult was made with cardiothoracic surgery.  The patient plans to return to see Dr. Elmer Fudd in the office to schedule surgery.

DISPOSITION:  The patient was discharged to home in stable condition later that day.  He was continued on his preadmission medical regimen.  A low-fat, low-cholesterol diet was recommended.  He is to gradually increase activities as tolerated.  Followup with Dr. Elmer Fudd is planned on August 7, 2002 at 11:30 a.m.