176318078_a
FIH
4189699
28872/d70h
094756
11/03/1993 12:00:00 AM
MITRAL STENOSIS
Unsigned
DIS
Report Status :
Unsigned
ADMISSION DATE :
11-03-93
DISCHARGE DATE :
11-06-93
PRINCIPAL DIAGNOSIS :
Mitral stenosis
ASSOCIATED DIAGNOSIS :
Tricuspid regurgitation , heart failure , chronic atrial fibrillation , chronic ventricular ectopy , chronic obstructive lung disease .
ADVERSE DRUG REACTIONS :
Epistaxis to Coumadin in the past .
PRINCIPAL PROCEDURE :
Cardiac catheterization 11/03 .
OTHER PROCEDURE :
Pulmonary function test 11/04 .
HISTORY OF PRESENT ILLNESS :
This 68-year-old patient of Dr. Naka Jesc had two episodes of rheumatic fever as a teenager .
She has had chronic atrial fibrillation .
Coumadin has caused bleeding from the mouth and nose on two occasions , on one occasion with prothrombin time 13 , and has been replaced by anti-platelet agents .
She has had recurrent syncope since age 6 .
She has now had progressive heart failure .
A Holter showed atrial fibrillation with period of ventricular bigemini .
She cut down dramatically on smoking two years ago , but has continued to smoke , although , very recently , she admits to only " two puffs " per day .
She has not had hypertension or diabetes , and says he has lowered her cholesterol from 333 to 197 by changing her diet .
There is no family history of heart disease .
She has been treated with Vanceril for chronic obstructive pulmonary disease .
She has had one gram per day proteinuria with normal creatinine .
She had a partial gastrectomy in 1972 for a " tumor " .
She has had an appendectomy and cholecystectomy .
MEDICATIONS ON ADMISSION :
Digoxin 0.125 mg po q.d. , Lasix 40 mg b.i.d. , aspirin held , and Vanceril three puffs b.i.d.
ALLERGIES :
Transdermal nitroglycerin caused headache .
SOCIAL HISTORY :
She does not drink .
PHYSICAL EXAMINATION :
Heart rate 86 , irregularly irregular , blood pressure 142/86 .
Neck veins distended .
Carotids normal .
Chest clear .
Apical impulse not palpable .
Right ventricular heave .
S1 normal .
S2 narrowly physiologically split with accentuation of P2 .
No S3 or opening snap .
Grade II systolic murmur at the left lower sternal border .
Grade II decrescendo diastolic murmur at the left lower sternal border .
Diastolic rumble at the apex .
Liver slightly pulsatile but no enlarged .
Pulses normal to the femorals with weak dorsalis pedis pulses .
Superficial varicose veins .
No edema .
LABORATORY DATA :
Hematocrit 44 , potassium 4.0 , BUN 23 , creatinine 1.2 , blood sugar 115 , Digoxin 1.4 .
Electrocardiogram showed atrial fibrillation , moderate ventricular response , incomplete right bundle branch block , right axis deviation , right ventricular hypertrophy and possible apical infarction .
Chest x-ray showed left atrial , right ventricular and pulmonary arterial enlargement and interstitial edema with small , bilateral effusions .
HOSPITAL COURSE :
Cardiac catheterization was performed without complication from the right neck and right groin on the day of admission .
Right atrial pressure was 12 with a wave form consistent with tricuspid regurgitation .
There was no tricuspid valve gradient .
Pulmonary artery pressure was markedly elevated at 120/60 .
Pulmonary capillary wedge pressure was markedly elevated at 38 , with a very large mitral valve gradient .
There was little or no aortic valve gradient .
Fich cardiac output was 3.0 and indexed 2.0 .
Arterial oxygen saturation was 85 percent .
There was minimal mitral valve calcification , normal left ventricular contraction , and 2+ mitral regurgitation into a large left atrium .
There was minimal aortic valve calcification , mild ______________ thickening , normal open , and mild aortic regurgitation .
There was mild atherosclerosis of the mid left anterior descending .
FVC was 1.6 or 58 percent of predicted and FEV1 0.95 or 45 percent of predicted .
Room air arterial blood gas was 56/40/7.45 .
Because it would be ideal to place a mechanical valve if valve replacement rather that commissurotomy is needed , she was seen by Dr. Ca Shuff of ENT for her history of epistaxis .
He identified no bleeding source , but felt that the risk of nasal hemorrhage on Coumadin could be minimized interventional neuroradiology occlusion of the arteries to the nose bilaterally .
The patient was therefore referred to the Dr. A Eu Wave .
The procedure could not be scheduled during this admission .
The patient is , therefore , discharged after a three day hospitalization , with plans for re-admission for the neuroradiology procedure .
This will be followed by a trial of Coumadin , and then by mitral commissurotomy or replacement and probable tricuspid annuloplasty by Dr. Riemund C. Wave .
In the meantime , Lasix dosage is increased .
Potassium replacement has caused , according to the patient , marked hyperkalemia in the past .
DISCHARGE REGIMEN :
Digoxin 0.125 mg q.d. , Lasix 80 mg q.a.m. and 40 mg q.p.m. aspirin 1 q.d. , and Vanceril three puffs b.i.d.
CA SHUFF , M.D.
TR :
vw / bmot
DD :
11-06-93
TD :
11/07/93
CC :
Copies to Dr. Bodejove at Valtawnprinceel Community Memorial Hospital , Dr. A Eu Wave , Dr. Riemund C. Wave , and three copies to Dr. Ca Shuff edited 12/31/93 qm