tokens: 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has caused bleeding from the mouth and nose on two occasions , on one occasion with prothrombin time 13 , and has been replaced by anti-platelet agents .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 &quot; two puffs &quot; 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 &quot; tumor &quot; . 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