Medical Text: Admission Date:  [**2140-11-11**]       Discharge Date:  [**2140-11-24**]


Service:  CARDIOTHORACIC

HISTORY OF PRESENT ILLNESS:  The patient is a scheduled
admission by aortic aneurysm repair. This is an 81 year old
woman with a history of hypertension, who had recurrent
pericarditis and pleuritis requiring percutaneous drainage in
[**2137**].  An echocardiogram in [**2137-12-13**], showed normal left
ventricular function with a dilated aortic root of 48mm,
mildly thickened aortic valve with mild aortic regurgitation.
Follow-up in [**2140-9-12**], with echocardiogram showed an
ejection fraction of 60% with dilated aortic root at 55mm,
mild aortic sclerosis, mild aortic regurgitation, and
bilateral atrial enlargement.  Cardiac catheterization done
on [**2140-10-26**], showed an ejection fraction of 80% with normal
wall motion, severe aneurysmal dilatation of the ascending
aorta into the arch, recurrent dilatation in the descending
aorta with no dissection, 1+ aortic regurgitation, normal
coronaries.

PAST MEDICAL HISTORY:
1.  Hypertension.
2.  Raynaud's disease.
3.  Phlebitis.
4.  Osteoporosis.
5.  Tonsillectomy.
6.  Spinal fusion.
7.  Umbilical hernia repair.
8.  Appendectomy.
9.  Cholecystectomy.
10. Total abdominal hysterectomy.

MEDICATIONS ON ADMISSION:
1.  Metoprolol 100 mg twice a day.
2.  Hydrochlorothiazide 25 mg once daily.
3.  Lisinopril 10 mg once daily.
4.  Enteric Coated Aspirin 81 mg once daily.
5.  Centrum Silver one once daily.
6.  Calcium 600 once daily.
7.  Nexium 40 mg once daily.

ALLERGIES:  Stated allergy to Codeine which caused bad
abdominal cramps and adhesive tape which causes a rash.

SOCIAL HISTORY:  The patient lives at home with her husband.
[**Name (NI) 1139**] one half pack per day times eighteen years, quit
forty-five years ago.  Alcohol one drink per day, none times
the past four weeks.

PHYSICAL EXAMINATION:  At the time of preadmission testing,
the heart rate is 74 beats per minute, blood pressure 148/80,
respiratory rate 18, oxygen saturation 96% in room air,
height four feet eleven inches, weight 106 pounds.  In
general, she appears younger than stated age in no acute
distress.  Skin - no breaks or rashes.  Head, eyes, ears,
nose and throat - The pupils are equal, round, and reactive
to light and accommodation.  Extraocular movements are
intact.  Pharynx is clear. The neck is supple with no jugular
venous distention, no bruits, carotid pulses are 2+
bilaterally.  The chest is clear to auscultation bilaterally.
The heart is regular rate and rhythm, no murmurs, rubs or
gallops.  The abdomen is soft, nontender, nondistended,
positive bowel sounds, no hepatosplenomegaly, well healed
surgical scars.  Extremities without cyanosis, clubbing or
edema.  Left upper extremity with nodularity at old
intravenous site near the left wrist.  No varicosities in the
lower extremities.  Neurologically, the patient is alert and
oriented times three, grossly intact.  Pulses - femoral not
indicated.  Dorsalis pedis 1+ bilaterally.  Posterior tibial
not detected.  Radial 2+ bilaterally.  No carotid bruits
bilaterally.

HOSPITAL COURSE:  As stated previously, the patient was a
direct admission to the operating room on [**2140-11-11**], at which
time she underwent a supracoronary ascending aortic graft
with a resuspension of the aortic valve.  Please see the
operative report for full details.   The patient tolerated
the operation well and was transferred from the operating
room to Cardiothoracic Intensive Care Unit.  Circ arrest time
was eleven minutes.  At the time of transfer, the patient had
Milrinone at 0.4 mcg/kg/minute, Amiodarone at 1 mg per
minute, Neo-Synephrine no dose indicated and Propofol, also
no dose indicated.  The patient did well in the immediate
postoperative period.  Her anesthesia was reversed.  She was
weaned from the ventilator.  In the morning of postoperative
day one, she was successfully extubated.  On postoperative
day number one, her cardioactive medications were begun to be
weaning beginning with Amiodarone and Milrinone.  By
postoperative day two, the patient was maintained with
minimal amounts of Amiodarone, Milrinone and Nipride.  On
postoperative day two, the patient's Milrinone was
discontinued.  Her Amiodarone was changed to p.o.  Her
Nipride was discontinued with initiation of beta blockade.
Her chest tubes were removed.  She was maintained in the
Cardiothoracic Intensive Care Unit for monitoring of her
hemodynamic and pulmonary status.  On postoperative day
three, the patient continued to do well.  She remained
hemodynamically stable.  She was transferred from the
Cardiothoracic Intensive Care Unit to [**Hospital Ward Name 121**] Two for continuing
postoperative care and cardiac rehabilitation.  Once on the
floor, it was noted that the patient had gone into sustained
atrial fibrillation with a heart rate of 100 to 110,
hemodynamically tolerated well.  She was seen by the
electrophysiology service and was maintained on her p.o.
Lopressor as well as her p.o. Amiodarone and continued to be
monitored on the floor.  Over the next two days, the patient
was in and out of atrial fibrillation.  She remained
hemodynamically stable throughout these periods.  On
postoperative day five, it was noted that the patient had a
drop in her hematocrit with guaiac positive stools.  She was
seen by the gastroenterology service.  At that time, she was
also transferred back to the Cardiothoracic Intensive Care
Unit for close monitoring.  The patient underwent a KUB which
was read as normal.  She also had stools sent for Clostridium
difficile which were negative.  She was empirically started
on Flagyl at that time.  The patient remained in the
Intensive Care Unit for the next several days to monitor her
gastrointestinal status to make sure that she had no further
guaiac positive stools.  On postoperative day seven, she was
again transferred to the floor for continuing postoperative
care.  Prior to transfer from the Intensive Care Unit, it was
noted that the patient had some left upper extremity
swelling.  She underwent ultrasonography of her upper
extremities at that time to rule out a thrombosis.
Ultrasound showed a right internal jugular and cephalic
thrombus.  Following transfer, the vascular service was
consulted and they recommended oral anticoagulation with
Coumadin, which was begun at that time.  Over the next
several days, with the exception of intermittent atrial
fibrillation, the patient had an uneventful hospital course.
She was again seen by the electrophysiology service given her
episodes of atrial fibrillation, the last episode lasting
greater than 24 hours.  The patient was additionally begun on
Heparin given the duration of this episode of atrial
fibrillation.  The patient was scheduled for a direct current
cardioversion, however, prior to cardioversion, the patient
spontaneously converted to normal sinus rhythm.   On
postoperative day twelve, it was decided that if the patient
remained in a rate controlled rhythm for the next 24 hours,
she would be stable and ready to be transferred to
rehabilitation.

At the time of this dictation, the patient's physical
examination is as follows;  vital signs revealed temperature
98.2, heart rate 71, sinus rhythm, blood pressure 147/68,
respiratory rate 20, oxygen saturation 98% in room air.
Weight preoperatively was 50 kilograms and at transfer to
rehabilitation is 53 kilograms.  Laboratory data on [**2140-11-23**],
white blood cell count 11.7, hematocrit 34.5, platelet count
219,000.  Prothrombin time 15.0, partial thromboplastin time
25.0 with Heparin off.  INR is 1.5.  Sodium is 129, potassium
4.8, chloride 95, CO2 29, blood urea nitrogen 16, creatinine
0.8, glucose 183.  The patient is alert and oriented times
three, moves all extremities, follows commands.  Respiratory
revealed scattered rhonchi.  Cardiac is regular rate and
rhythm with no murmur.  The sternum is stable and incision
with Steri-strips open to air, clean and dry.  The abdomen is
soft, nontender, nondistended with positive bowel sounds.
Extremities are warm and well perfused with no edema.  Right
upper arm with minimal edema which has been resolving over
the last several days.

MEDICATIONS ON DISCHARGE:
1.  Colace 100 mg p.o. twice a day.
2.  Amiodarone 200 mg p.o. three times a day times one week
and then 200 mg p.o. once daily times one month.
3.  Metoprolol 100 mg twice a day.
4.  Lasix 20 mg once daily times ten days.
5.  Potassium Chloride 20 meq once daily times ten days.
6.  Prilosec 40 mg p.o. once daily.
7.  Heparin 600 units per hour to keep partial thromboplastin
time 40 to 60 until INR is therapeutic.
8.  Warfarin to maintain an INR between 2.0 and 2.5.   The
patient received 2 mg of Coumadin two days prior to discharge
and no Coumadin on one day prior to discharge and 2 mg of
Coumadin on the night before discharge.  We will check the
INR in the morning and dose Coumadin on the day of transfer
to rehabilitation center.

CONDITION ON DISCHARGE:  Good.

DISCHARGE DIAGNOSES:
1.  Status post supracoronary ascending aortic graft with a
resuspension of the aortic valve.
2.  Hypertension.
3.  Raynaud's disease.
4.  Phlebitis.
5.  Osteoporosis.
6.  Status post tonsillectomy.
7.  Status post spinal fusion.
8.  Status post umbilical hernia repair.
9.  Status post inguinal hernia repair.
10. Status post appendectomy.
11. Status post cholecystectomy.
12. Status post total abdominal hysterectomy.

DISCHARGE STATUS:   The patient is to be discharged to [**Location 50742**].

FO[**Last Name (STitle) **]P:  She is to have follow-up with Dr. [**First Name (STitle) **] in two to
three weeks and follow-up with Dr. [**Last Name (STitle) 1159**] in one month and
follow-up with Dr. [**Last Name (Prefixes) **] in one month.




                            [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D.  [**MD Number(1) 414**]

Dictated By:[**Name8 (MD) 415**]
MEDQUIST36

D:  [**2140-11-23**]  16:44
T:  [**2140-11-23**]  18:31
JOB#:  [**Job Number 50743**]

ICD9 Codes: 4241, 4019