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Autopsy Conference03/02/2016Khushboo Gandhi, MD PGY 1, St Lukes Hospital IM residency program

History of Present Illness:79-year-old WM presents with chest pain and SOB on exertion. Ten days ago - chest pain, tightness on anterior chest, with palpitation, resolved with sublingual nitroglycerin. Past three to four days - chest pain continued despite NTG now radiating to left arm. Shortness of breath on exertion and feeling tired easily. Ten days ago - took Pseudoephedrine for allergy. He went to Salem Township hospital, Troponins mildly elevated 0.15, BNP 180. Received NTG sublig, Lasix 80 mg, Nitro-patch and heparin bolus, transferred to St Luke's' telemetry as his cardiologist was here.

Past Medical and Surgical history:CAD s/p CABG x 5 in 1982, attempt at a PCI in 2008 with balloon angioplasty, MI in 2011Recent cardiac catheterization in December 2014 - total occlusion of the native circulation and patent but severely diseased 2 out of 3 venous graftsInfrarenal AAA 5.4 X 4 cm, follows vascular surgeon, USG every 6 monthsTransient ischemic attack in 12/2014left subclavian arterial aneurysm and an aberrant right subclavian artery s/p bilateral carotid-subclavian bypass and TEVAR with stent placement and embolization of the bypassed segments of the bilateral subclavian arteries in January 2015.Hypertension HyperlipidemiaChronic Kidney Disease

OSA on CPAP during night History of gastric ulcersOsteoarthritisHernia repair

Family History:heart disease and hypertension in father

Social Hx:Tobacco Use - Quit in 2008Alcohol Use - occasional beer per week or 2 weeks.Recreational Drug Use - Never drug user

Home meds:Crestor 40 mg, Metoprolol Succinate ER 25 mg, Nitrostat 0.4 mg sublingual, Norco 5 mg-325 mg, Plavix 75 mg, Viagra 100 mg, amLODIPine 5 mg, aspirin 81 mg, cloNIDine 0.1 mg, fluticasone nasal spray, furosemide 20 mg as needed, omeprazole 20 mg.

Physical Exam: VITAL SIGNS: Temperature 36.6, heart rate 80, respiratory rate 18, O2 saturation 96% on room air, blood pressure 137/89. Height 177 cm, weight 97.2, body mass index 31.03. CONSTITUTIONAL: No fever or chills.GENERAL APPEARANCE: Looks appropriate for his age. Well-built, well-nourished appearance. HEAD: Normocephalic, atraumatic.MOUTH AND NOSE: Normal mucosa.EYES: Anicteric sclerae. Normal conjunctivae. Pupils equal, round, and reactive to light and accommodation. No sinus tenderness with palpation. Normal ears and hearing. NECK: Supple. No visible jugular venous distention. No palpable mass or thyromegaly. No carotid bruits heard. HEART: Irregularly irregular. Unable to appreciate any audible murmur, gallop, or rub. LUNGS: Clear to auscultation bilaterally without any added sounds currently. CHEST WALL: No tenderness with palpation. ABDOMEN: Positive bowel sounds. Soft and nontender.EXTREMITIES: Very trace edema bilaterally. Palpable weak pedal pulses. No calf tenderness. No tremors. BACK: No spine tenderness. No costovertebral tenderness.

Labs:

Troponins: 0.15 0.82 1.70 1.58

EKG: Atrial fibrillation, Rightward axis, Nonspecific ST abnormality Compared to prior on 11-Dec-2014: ST abnormality is new

CHEST 2 VIEWS 11/11/2015 - unremarkableSmall left pleural effusion or pleural scar, Postoperative changes. No definite infiltrate.

Assessment and plan:Symptomatic new onset of atrial fibrillation with moderate ventricular response heart rate around 90s, likely secondary to recent OTC medication, pseudoephedrine and Claritin-D. Before transfer, he received 25 mg of metoprolol and heparin bolus. Seen by cardiologist, and on subcutaneous Lovenox, metoprololElevated troponin - non-ST elevated myocardial infarctionHistory of coronary artery disease - known complex coronary anatomy with bypass surgery more than 30 years ago and attempt at a percutaneous intervention in 2008, stents could not be deployed, but he did have balloon angioplasty. On aspirin, Plavix, statin, metoprolol, nitroglycerin patch.Cardiac catheterization in December 2014 - showed total occlusion of the native circulation and patent but diseased grafts to marginals, patent graft to the LAD, and a patent graft to the right coronary artery with disease in the posterior descending distal to it.History of abdominal aortic aneurysm, 5.2x4 cm in size, follows vascular surgeon, usg q 6 monthsDyslipidemia, on statin.Chronic diastolic congestive heart failure on small dose of furosemide. chronic kidney disease stage II. Hypertension on Imdur and metoprolol, amlodipineHistory of recent transient ischemic attack in 12/2014, on aspirin, Plavix, and statin. History of right subclavian bypass surgery January 12, 2015, and Left carotid subclavian artery bypass, thoracic aortic stent graft placement, bilateral subclavian artery embolization 01/19/2015. History of gastric ulcers status post upper endoscopy, colonoscopy in September 2011 for melena, on omeprazole.Ex-tobacco use, quit in 2008, No COPD.

Day 2 11/12/2015Patient still in A. fib with moderate ventricular response, HR 80s/minAngina, currently controlledElevated troponin trending down (1.70 1.58 0.82)Repeat EKG - No Significant Changes compared t0 11/11/2015Decided against cardiac cath - as troponin trending down and according to patient wish. if symptoms persist, he would need cardiac cath and possible CABG redo Dyspnea, resolved. Decided against CT chest or USG of lower ext for suspected PE, as pt already received 2-3 dose of Lovenox, and in the absence of calf pain, lovenox discontinued later that day.

Echo 11/12/20151.The rhythm during the study was atrial fibrillation.2.Mild to moderate concentric left ventricular hypertrophy.3.Normal left ventricular diastolic function for age as measured by tissue Doppler/Mitral Doppler indices.4.Normal left ventricular cavity size and systolic function. The left ventricular ejection fraction is measured at 54%.5.There is mild left atrial enlargement.6.Mild focal thickening of the anterior mitral valve leaflet.7.Mild mitral regurgitation.8.Tricuspid aortic valve. Trace aortic regurgitation. No significant aortic stenosis.9.Tricuspid regurgitant jet velocity envelope is inadequate for determination of RVSP.10.Compared to prior study of 12/12/2014, there is no significant change.

Day 3 11/13/2015Pt felt greatLabs unremarkableDischarged homeDISCHARGE MEDICATIONS:1. Acetaminophen/hydrocodone 5 mg/325 mg 1 tablet oral every 4 hours p.r.n. for pain. 2. Loratadine 10 mg oral daily.3. Amlodipine 5 mg oral daily.4. Eliquis 5 mg oral b.i.d. for 30 days.5. Clonidine 0.1 mg oral p.r.n. for high blood pressure.6. Plavix 75 mg oral daily.7. Fluticasone, 1 spray nasal b.i.d.8. Furosemide 20 mg oral as needed.9. Imdur 30 mg oral daily.10. Metoprolol 25 mg oral daily.11. Nitroglycerin 0.4 sublingual as needed p.r.n. for chest pain.12. Omeprazole 20 mg oral daily.13. Crestor 40 mg orally at bedtime.

Day 4 11/14/2015Pt presented to ER with worsening chest discomfort associated with some nausea and minimal diaphoresis.

Physical examination:Elderly white male, currently in no acute distress, alert, oriented, and cooperative. Vitals: afebrile. Pulse 96, atrial fibrillation, respirations 18, blood pressure 120/90. Neck is supple without jugular venous distention. Lungs are clear. Heart is irregularly irregular. There is a grade 2/6 systolic ejection murmur. No diastolic murmur and no gallop. Radial, carotid, and femoral pulses are palpable. Pedal pulses are diminished. Abdomen is unremarkable. EXTREMITIES: No significant edema.

EKG: Course Atrial fibrillation, Rightward axis, Nonspecific ST abnormality , probably digitalis effectCompared to prior on 12-Nov-2015: No Significant Changes

CHEST SINGLE VIEW: No acute process or significant change in the chest.

Labs: CBC unremarkable, BUN 22, Creatinine 1.4, Troponin 1.64Serial troponins: 1.64 11.80

Plan: Admitted to telemetry, However as chest pain was relieved, plan was made to continue medical management. In case of recurrent angina, consider catheterization. Imdur and metoprolol dose doubled.

Day 5 11/15/2015 Pt asymptomatic, 2 episodes of NSVT (6 beats) during nightTroponin trending down to 1.64 11.8 8.57 3.53A fib. rate controlled, HR in 70s-80s

Same day @ 1716On call resident was called for chest pain, HR 110s/min, BP 160/112Chest pain resolved after two sublingual NTG.Trop stat 3.53Repeat EKG: Atrial fibrillation with rapid ventricular responseRightward axisMarked ST abnormality, possible inferolateral subendocardial injuryCompared to prior on 14-Nov-2015: HR is faster and ST changes are more pronounced

Serial troponins: 3.53 3.69 2.59

Day 6 11/16/2015Pt was taken for cardiac catheterization Report:1. Normal left ventricular ejection fraction approximately 55% with anterolateral hypokinesia. 2. Moderately elevated LVEDP of 17 mmHg.3. No mitral regurgitation.4. Severe native 3-vessel coronary artery disease.5. Left internal mammary artery to the left anterior descending is patent and visualized by a nonselective ascending aortogram. 6. The saphenous vein graft to the right posterior descending artery is patent with an ostial posterior descending artery stenosis of 80%. 7. The saphenous vein graft to the first diagonal branch of the left anterior descending has a 60% to 70% ostial stenosis. 8. The saphenous vein graft to the second obtuse marginal branch has a 99% ostial stenosis and 60% stenosis at the vein graft anastomosis.

Decision was made to proceed with redo coronary artery bypass grafting. Plavix and eliquis discontinued and Heparin drip was started.

Day 7-9 Transferred to the cardiovascular step down unit and cardiothoracic surgery was consulted for redo sternotomy, redo coronary artery bypass grafting, and possible left atrial appendage excision and pulmonary vein isolation for atrial fibrillation. Surgery was planned

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