tokens: Admission Date : 2013-02-12 Discharge Date : 2013-02-16 Date of Birth : 1937-03-25 Sex : F Service : CARDIOTHORACIC HISTORY OF PRESENT ILLNESS : The patient was referred from an outside hospital with a chief complaint of increasing shortness of breath and tires easily with exertion . Admitted to Bay State Medical Center Hospital in 2012-10-22 in congestive heart failure at that time . Via echocardiogram , found to have aortic stenosis . Referred to Memorial Hospital ( Worcester ) for cardiac catheterization to further evaluate her aortic stenosis . Cardiac catheterization done on 01-07 showed an aortic valve area of .38 cm.sq. , with a mean gradient of 62 , and a peak gradient of 85 . Moderate pulmonary hypertension , PA pressure 48/24 , 1+ mitral regurgitation , severe aortic stenosis with an LVEDP of 19 and an ejection fraction of 43% . She was then referred to Cardiothoracic Surgery for aortic valve replacement . PAST MEDICAL HISTORY : 1. Aortic stenosis 2. Diabetes mellitus Type 2 3. Right hip replacement 4. Noninsulin dependent diabetes mellitus MEDICATIONS ON ADMISSION : Include Glucovance 5/500 one tablet twice a day , Univasc 7.5 mg once daily , lasix 20 mg every other day , and aspirin 325 mg once daily . ALLERGIES : No known drug allergies . FAMILY HISTORY : Significant for her father , who died at 50 years from myocarditis . SOCIAL HISTORY : She lives alone in Methuen with five stairs . She has a remote tobacco history , quit in October , one pack per day for 50 years . No alcohol use . PHYSICAL EXAMINATION : Vital signs : Heart rate 108 and regular , blood pressure 145/76 , respiratory rate 20 , height 5'2" , weight 141 pounds . General : Healthy-appearing woman , in no acute distress . Skin : No lesions or rashes . Head , eyes , ears , nose and throat : Pupils equal , round and reactive to light , extraocular movements intact , anicteric , not injected . Oropharynx : Mucous membranes moist . Neck : Supple , no lymphadenopathy , no jugular venous distention , no thyromegaly . Chest : Clear to auscultation bilaterally . Heart : Regular rate and rhythm , S1 , S2 , with III/VI blowing murmur . Abdomen : Soft , nontender , nondistended , normal active bowel sounds , no hepatosplenomegaly . Extremities : Warm and well perfused , with no cyanosis , clubbing or edema , no varicosities . Neurological : Cranial nerves II through XII grossly intact . Moves all extremities . Strength 5/5 in upper and lower extremities . Sensation intact in all dermatomes . Pulses : Femoral 2 + bilaterally , dorsalis pedis 1 + bilaterally , posterior tibial 1 + bilaterally , and radial 2 + bilaterally . No carotid bruits were noted . LABORATORY DATA : White count 5.3 , hematocrit 43 , platelets 200 . Sodium 138 , potassium 4.9 , chloride 102 , CO2 25 , BUN 24 , creatinine 0.9 , glucose 309 . Electrocardiogram : Rate of 91 , first degree AV block , intervals .22 , .92 , .36 , with left ventricular hypertrophy . Chest x-ray is pending at the time of physical . HOSPITAL COURSE : The patient was a direct admission to the operating room on 02-12 , at which time she underwent an aortic valve replacement . Please see the operative report for full details . In summary , she had an aortic valve replacement with a #21 mosaic porcine valve . She tolerated the operation well , and was transferred from the operating room to the Cardiothoracic Intensive Care Unit . The patient did well in the immediate postoperative period , however , her blood pressure remained somewhat labile . Therefore , she was continued on a Neo-Synephrine drip to maintain a systolic blood pressure greater than 110 . In addition , she was slow to awaken after her anesthesia was reversed , and in several attempts to wean from the ventilator , she developed a respiratory acidosis . She therefore remained on the ventilator throughout the day of postoperative day one . On postoperative day two , the patient remained hemodynamically stable . Her Neo-Synephrine drip was weaned to off . She was again weaned from the ventilator , and successfully extubated . Her chest tubes were discontinued and , at the end of the day , she was transferred from the Cardiothoracic Intensive Care Unit to the floor for continuing postoperative care and cardiac rehabilitation . After being transferred to the floor , the patient did well . Over the next several days , her activity level was increased with the assistance of Physical Therapy and the nursing staff . She remained hemodynamically stable . Her respiratory condition remained stable and , on postoperative day four , she was deemed stable and ready to be transferred to rehabilitation for continuing postoperative care and physical therapy . At the time of transfer , the patient 's physical examination is as follows : Vital signs : Temperature 98.4 , heart rate 78 and sinus rhythm , blood pressure 106/50 , respiratory rate 18 , oxygen saturation 97% on room air . Weight preoperatively was 67 kg , at discharge is 70.9 kg . Laboratory data on 02-15 : White count 4.1 , hematocrit 23 , platelets 144 . Sodium 141 , potassium 4.3 , chloride 108 , CO2 25 , BUN 24 , creatinine 0.8 , glucose 140 . Physical examination : Alert and oriented x 3 , moves all extremities , conversant . Respiratory : Scattered rhonchi with diminished breath sounds in the bases . Cor : Regular rate and rhythm , S1 , S2 , with soft systolic ejection murmur . Sternum is stable . Incision with staples , open to air , clean and dry . Abdomen : Soft , nontender , nondistended , normal active bowel sounds . Extremities : Warm and well perfused , with no cyanosis , clubbing or edema . DISCHARGE MEDICATIONS : Ranitidine 150 mg twice a day , enteric-coated aspirin 325 mg once daily , Glucovance 5/500 one tablet twice a day , metoprolol 25 mg twice a day , Furosemide 20 mg once daily for 14 days , potassium chloride 20 mEq once daily for 14 days , Colace 100 mg twice a day , Niferex 150 mg once daily , Percocet 5/325 one to two tablets every four hours as needed , ibuprofen 400 mg every six hours as needed . DISCHARGE DIAGNOSIS : 1. Aortic stenosis status post aortic valve replacement with a #21 mosaic porcine valve 2. Diabetes mellitus Type 2 3. Right hip replacement CONDITION ON TRANSFER : Stable . DISCHARGE INSTRUCTIONS : She is to have follow up with Dr. Bloomfield in one month , and follow up in the Wound Clinic in two weeks . Alice S. Shadle , M.D. 37-538 Dictated By : James F. Buchanan , M.D. MEDQUIST36 D : 2013-02-15 18:35 T : 2013-02-16 01:03 JOB #: 59205 Signed electronically by : DR. Richard Gray on : Tommy 2013-02-17 12:05 AM ( End of Report )