CardiacNote
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School
University of South Alabama *
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MISC
Subject
Medicine
Date
Dec 6, 2023
Type
docx
Pages
6
Uploaded by DoctorFreedom788
1
Ruth Sobalvarro
University of South Alabama
AHN 573 - 801 Dr. Elizabeth Zellner, DNP, AGACNP-BC
May 8, 2022
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Patient Information
∙ Date of Clinical Encounter: May 8, 2022
∙ Age: >60 years old
∙ Race/Gender: White/Male
∙ Information/Source/Reliability: Patient is alert, awake, and oriented to name, date of birth,
place, and time. He is a reliable historian.
∙ Health Insurance: Medicare/Medicaid
Chief Complaint
∙ “I have worsened shortness of breath and my legs are big.”
History of Present Illness
∙
Patient is a >60 years old male with a PMHx of CHF, CAD s/p PCI, HTN, A-fib, anemia,
dyslipidemia, GI bleed, tobacco use, COPD, VT/PVCs, hernia repair, s/p ablation
4/1/2022 for atrial flutter, s/p AICD 5/2020, STEMI/LHC 3/22/22. Patient states that he
has had progressive shortness of breath, orthopnea, and lower extremity swelling over
the last two days since seen in his clinic. He denies chest pain. CTA chest shows-
atherosclerotic thoracic aorta and associated CAD. Cardiomegaly. Enlarged mediastinal
and bilateral hilar adenopathy. Emphysema with pleural parenchymal. Fatty infiltration.
Marked ascites. BNP-2901, Troponin- 317, Echo: 5/2020 shows EF: 20-25 %. CXR-
stable cardiac enlargement. Stable appearance of a left subclavian pacemaker
defibrillator device. Mild perihilar vascular congestion but otherwise the lungs are clear.
No pneumothorax. No pleural effusion. EKG- Sinus rhythm with right bundle branch
block and PVCs.
Past History
∙ General overall health: Poor
∙ Childhood illnesses: Denies childhood illnesses
∙ Adult illnesses/Chronic conditions:
o Congestive Heart Failure
o Hypertension
o Anemia
o Coronary artery disease with Percutaneous Intervention
o Atrial Fibrillation
o Dyslipidemia
o Tobacco use
o Chronic Obstructive Pulmonary Disease
∙ Surgical History/Past Hospitalizations
o AICD (2020)
o STEMI/LHC (2022)
o Ablation for atrial flutter (2022)
o Hernia repair
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∙ Injuries/Accidents
o None
∙ Immunizations
o Covid (2020) Pneumonia Vaccine (2019)
∙ Screenings
o Non-compliance with screenings
∙ Family History:
o Paternal grandfather: Hypertension, DM, deceased (82)
o Paternal grandmother: Hypertension, stroke (60)
o Maternal grandfather: Coronary artery disease, deceased (71)
o Maternal grandmother: DM, deceased (64)
o Mother: Cerebrovascular accident, deceased (67)
o Father: Coronary artery disease, deceased (71)
o Sister: Hypertension, living (59)
∙ Personal/Social History:
o Exercise: Sedimentary lifestyle
o Diet: American
o Safety Measures: +seatbelts, +smoke detectors in house
o Present Medications:
▪ Aspirin 325 mg tab, PO, Daily
▪ Atorvastatin 40 mg tab, PO, Bedtime
▪ Folic Acid 1 mg tab, PO, Daily
▪ Levothyroxine 25 mcg tab, PO, Daily
▪ Lisinopril 10 mg tab, PO, Daily
▪ Spironolactone 12.5 mg tab, PO, Daily
▪ Prednisone 5 mg tab, PO, Daily
▪ Apixaban 5 mg tab, PO, BID
▪ Pantoprazole 40 mg tab, PO, Bedtime
▪ Folic Acid 1 mg tab, PO, Daily
▪ Levothyroxine 25 mcg tab, PO, Daily
▪ Lisinopril 10 mg tab, PO, Daily
▪ Metoprolol tartrate 25 mg tab, PO, Daily
▪ Prednisone 5 mg tab, PO, Daily
o Allergies: No known drug/food allergies
o Spiritual/Cultural Considerations: None
o Alcohol: Never
o Tobacco: Former Smoker; quit > 5 years ago
o Electronic Cigarette/Vaping: Never
o Substance Abuse: Never
Review of Systems
∙ General: calm; no distress reported
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4
∙ HEENT: no abnormalities reported
∙ Cardiovascular: chest tightness on exertion
∙ Respiratory: denies shortness of breath/cough
∙ Abdomen: no abnormalities reported
∙ Extremities: no abnormalities reported
∙ Neurologic: no abnormalities reported
∙ Skin: no abnormalities reported
Physical Exam
∙ General: no distress; calm, cooperative
∙ HEENT: no pallor, icterus; mucous membranes pink/moist
∙ Cardiovascular: S1S2, clear, regular
∙ Respiratory: unlabored, lungs clear
∙ Abdomen: soft, non-tender; hyperactive bowel sounds
∙ Extremities: no edema, no cyanosis; pulses palpable, +2
∙ Neurologic: alert/oriented x 4; responds appropriately
∙ Skin: no breakdown
Differential Diagnoses
∙ Chronic stable angina (I20.9)
∙ Coronary artery disease (I25.10)
∙ Acute chest pain, unspecified (R07.9)
Labs and Diagnostics
∙ CBC, BMP
o Necessary to understand patient standing in regards to white blood cell count,
hemoglobin and hematocrit, electrolyte balance and kidney function prior to
prescribing medication, diagnosing and/or planning for surgical procedure. o
WBC 7.6
o Hgb 13.7
o Hct 14.4
o Plt 264
o Na 138
o K 4.0
o CO2 25
o Cl 107
o Cr 0.93
o BUN 27**
o Glucose Random 103**
o Mg 2.1
o Ca 9.1
o PT 12.7
o INR 0.96
o PTT 29.9
o Troponin-I 21
5
o Total CK 21
∙ Left heart catheterization, selective coronary angiography, left ventriculography o 70%
stenosis in the distal left main with 40% stenosis in the proximal left main**.
o The
circumflex is occluded**.
o A large ramus branch is 90% stenosed**.
o The LAD has a proximal 70% stenosis with another distal 80% stenosis**.
o Diagonal branch has a 90% stenosis**. It is small.
Jennifer Johnston
Dr. Stephanie Williams
2/21/22
Primary Rotation
o The RCA is large, had a 50% stenosis at the ostium, the 2 lesions in the mid
portion 99%, in the distal portion 99% with a lot of tortuosity**.
o The posterolateral branch has a 50% stenosis**.
o Ejection fraction of 55%.
Assessment
Diagnosis with ICD Code(s)
∙ Coronary artery disease (I25.10)
o Based on the left heart catheterization results, the patient can be diagnosed with
coronary artery disease (McPhee & Papadakis, 2022).
∙ Chronic stable angina (120.9)
o Based on the patient’s description of her symptoms and the myocardial imaging
study results, the patient can be diagnosed with chronic stable angina (McPhee &
Papadakis, 2022).
∙ Hypertension (I10)
o Hypertension can contribute to atherosclerosis in the vessels of the heart (McPhee
& Papadakis, 2022).
∙ Type II Diabetes Mellitus (E11)
o Diabetes can contribute to atherosclerosis in the vessels of the heart (McPhee &
Papadakis, 2022).
Plan
Plan of Care
∙ Discussed with cardiothoracic surgeon with regards to plan for upcoming surgery. ∙
Tentative plan is coronary artery bypass graft x 3 on Monday.
o CABG surgery provides superior outcomes to percutaneous intervention in
patients with diabetes and multivessel coronary artery disease (McPhee &
Papadakis, 2022)
∙ Initiated heparin drip as patient is having exertional chest pain.
o Multiple studies have shown patients benefit from anticoagulation therapy with
stable angina, and with heparin’s short half-life, it is the right choice for pre
surgery anticoagulation therapy (McPhee & Papadakis, 2022).
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∙ Discussed with patient and RN.
o Educated patient on why heparin was ordered.
o Discussed with patient the risks and benefits of having a CABG to include
intubation, the weaning process and time of weaning, use of PT/OT the day of
extubation to get the patient up and moving, and the use of a foley catheter to
Jennifer Johnston
Dr. Stephanie Williams
2/21/22
Primary Rotation
manage and measure urine output and JP drains to manage drainage from the
surgical site. Answered patient’s questions.
o Patient will follow up with the cardiovascular surgeon the Wednesday following
discharge home from the hospital.
o Patient lives with son and has no social service needs. Patient is not spiritual. ∙
Problem List
o Hypothyroidism
o Hypertension
o Rheumatoid arthritis
o Coronary artery disease
o Diabetes Type II
o Chronic stable angina
References
McPhee, S. J. & Papadakis, M. A. (2022). Current medical diagnosis & treatment (61
st
ed).
Standford CT: Appleton & Lange.
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