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Patient Name MRN

"Progress MD at 12 /18/201810:17 AM (Date of

Service Note Date/Time)"
Author: Service: Internal Medicine Author Type:Physician
MD
Filed: 12/18/2018 3:44PM Note Type:Progress Notes Status: Signed
Editor:

Progress Note

Patient name:
Admit Date: 12/15/2018
Length of Stay: 3 days.

Subjective:

Denies angina
SOB continues to improve
No NN
No fevers
Denies cough

Objective:
Patient Vitals for the past 24 hrs:
Temp
BP Temp Pulse Resp SpO2 Weight
src
77.2 kg
12/18/18 0927 (170 lb
3.1 oz)
96.4 °F
12/18/18 0753 129/75 (35.8 ° Oral 66 18 96%
C)
96.9 °F
12/18/18 0434 103/66 (36.1 ° Oral 65 18 94%
C)
97.1 °F
12/17/18 2300 100/62 (36.2 ° Oral 67 18 99%
C)
96.8 °F
12/17/18 1930 105/61 Oral 67 18 95%
(36 °C)
12/17/18 1458 102/57 67 19 97%

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12/17/18 1214 60 21 96%

12/17/18 1209 91/50
98 °F
12/17/18 1200 (36.7 ° Oral 58 22 97%
C)
12/17/18 1155 (!) 83/43
12/17/18 1050 61 29 97%

Intake/Output Summary (Last 24 hours) at 12/18/2018 1017

Last data filed at 12/18/2018 0818
Gross per 24 hour
Intake 312 ml
Output 1050 ml
Net -738 ml

Gen: sitting, in NAO

HENT: NCAT, MMM, on NC
Eyes: anicteric, conjunctiva clear
Neck: supple, no thyromegaly
CV: RRR, no mrg
Pulm: ctab, no accessory muscle use
Abd: soft, NTND, no masses palpated
Ext: 1 + lower extremity edema, wwp
Neuro: awake and alert, grossly nonfocal CN exam
Mood: stable
Skin: no rash or induration
GU: no foley
Central lines: no

Labs: reviewed
Results for orders placed or performed during the hospital
encounter of 12/15/18 (from the past 24 hour(s))
BUN and Creatinine (Obtain baseline and then every 3 days,
if not already ordered) Status: Abnormal
Collection Time: 12/17/18 10:39 AM
Result Value Ref Range
BUN 32 (H) 7 -21 mg/dL
Creatinine 1.90 (H) 0.57-1.25
mg/dL
EGFR 33 mUmin/1.73 sq
m
Basic Metabolic Panel Status: Abnormal
Collection Time: 12/17/18 10:39 AM
Result Value Ref Range
Sodium 135 (L) 136-145
meq/L
Potassium 3.3 (L) 3.5-5.1 meq/L
Chloride 95 (L) 98-107 meq/L

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CO2 30(H) 22-29 meq/L

BUN 32(H) 7 -21 mg/dl
Creatinine 1.90 (H) 0.57-1.25
mg/dl
Glucose 157 (H) 70-105 mg/dl
Calcium 9.0 8.4 - 10.2
mg/dl
EGFR 33 mUmin/1.73 sq
m
Hemoglobin and hematocrit Status: Abnormal
Collection Time: 12/17/18 5:07 PM
Result Value Ref Range
Hemoglobin 11.0 (L) 13.7-17.5
GM/DL
Hematocrit 34.0 (L) 40.1 - 51.0 %
Hemoglobin and hematocrit Status: Abnormal
Collection Time: 12/18/18 4:38 AM
Result Value Ref Range
Hemoglobin 10.3 (L) 13.7-17.5
GM/DL
Hematocrit 31.0 (L) 40.1-51.0 %
Basic Metabolic Panel Status: Abnormal
Collection Time: 12/18/18 4:38 AM
Result Value Ref Range
Sodium 138 136 -145
meq/L
Potassium 4.1 3.5 - 5.1 meq/L
Chloride 96 (L) 98-107 meq/L
CO2 32(H) 22-29 meq/L
BUN 37 (H) 7-21 mg/dl
Creatinine 2.19(H) 0.57 -1.25
mg/dl
Glucose 113(H) 70-105 mg/dl
Calcium 9.3 8.4 - 10.2
mg/dl
EGFR 28 mUmin/1.73 sq
m

Micro: reviewed
Microbiology Results (last 7 days)
** No results found for the last 168 hours.**

Radiology: reviewed
Radiology Results (last day)
** No results found for the last 24 hours.**

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Meds:
Scheduled Meds:
• aspirin 81 mg Oral Daily 81 mg at
12/18/18 0914
• carvedilol 3.125 mg Oral BID 3.125mg at
12/17/18 2043
• cetirizine 10mg Oral Daily 10mg at
12/17/18 0840
• clopidogrel 75mg Oral Daily 75mg at
12/18/18 0914
• furosemide 20mg Oral Daily 20mg at
12/18/18 0914
• pantoprazole 40mg Oral Daily 40mg at
12/18/18 0914
• pravastatin 40mg Oral Daily 40mg at
12/18/18 0914
• rivaroxaban 10mg Oral BID 10mg at
12/18/18 0909
• spironolactone 25mg Oral Daily 25mg at
12/18/18 0914
• sucralfate 1g Oral 4x Daily 1 g at 12/18/18
0920

Continuous Infusions:
• sodium chloride 0. 9% (NS) Stopped (12/1 6/18 0600)

PRN Meds:.
• acetaminophen
• sodium chloride 0. 9% (NS)

Notable studies to date:

ASSESSMENT
The patient is a 90 y .o . M with h/o AAA s/p EVAR, PAD w/ bilateral occlusion of SFA, HTN,
HLD, ischemic CMY (EF37%), CAD s/p prior CABG, who presented for dyspnea, found to have
NSTEMI and CHF exacerbation .

PLAN
CV-
NSTEMI, CAD with prior ACB - management per cardiology - planned conservative approach
with medical rx
- asa, statin; bb resumed
- on heparin , off nitro gtt
- TIE shows LVEF of 35-39% . LAE, mild right CHF

Acute on chronic systolic CHF/ICMP - diuresis per cardiology, s/p bumex 2mg IV bid - now
transitioned to oral daily Lasix
- volume status is improved

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HTN- monitor bp with resumption of low dose coreg

HLD- statin

H/o AAA sip EVAR, h/o PVD with bilat occlusion of SFA- asa/statin

Pulm
On RA now

GI
GERO- cont ppi and carafate

Heme- monitor cbc

Renal -
AKI on CKD4 - cardiorenal. Diuresis per cardiology. Cr stable.
Hypomag- improved

GU - foleyout

Prophylaxis:
DVT: planned NOAC

Dispo- continue to mobilize. Home soon on medical rx

Discussed this case with pt and dt r

Notes reviewed.

Consultants/Teams on board:

Patient Name MRN

"H&P by 12/15/2018 5:27 PM (Date of Service Note Date/Time)"

Author: Service: Cardiology Author Type: Fellow
PM Note Type: H&P Status: Cosign Needed
Editor: Cosign Required: Yes
Expand All Collapse All

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Cardiology Admission H&P

Name:
Facility: SLEH
Date: 12/15/2018

HPI

CC: Dyspnea

This is a 90 y.o. male with a medical history significant for AAA s/p EVAR, PAD w/ bilateral
occlusion of SFA, HTN, HLD, ischemic CMY (EF37%), CAD s/p prior CABG, who presents to
ER after being dyspneic for 2 days.

Per daughter and patient, over the past week has had worsening heart failure symptoms
including DOE, NYHA II -> Ill symptoms. Called Dr. Lufschanowski's office and had his GDMT
held. Yesterday had an episode of epigastric discomfort and possible CP similar to his prior
angina, became dyspneic with minimal exertion and presented to the ER.

Initial EKG showed AVR elevation with some diffuse ST depressions with a troponin of 15,
determined to be not a STEMI and high risk for elective PCI given SFA occlusions. Decision
was made for medical management of his NSTEMI currently given anatomy and co-morbidities.

ROS: 10 systems reviewed negative aside from HPI

Assessment and CV Plan

#NSTEMI
#HTN
# lschemic CMY (EF 37% prior), not tolerating medical therapies, NYHA class IV
symptoms
#CAD s/p CABG
- holding all guideline directed medical therapies currently given concern of developing
shock
- bumex 2 IV BID
- nitro drip
- heparin
- ASA/Plavix
- trend troponins
- repeat echo
- medical management for now, low threshold for ionotropes

History

Medical
Past Medical History:

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Diagnosis Date
• Coronary artery disease
• Hyperlipemia
• Hypertension
• Myocardial infarction (HCC)

Surgical
Past Surgical History:
Procedure Laterality Date
• ABDOMINAL AORTIC ANEURYSM REPAIR
• CARDIAC SURGERY
bypass 1984
• CORONARY STENT PLACEMENT
• RELEASE,CARPAL TUNNEL
Converted from SIS-04/18/2012
• RELEASE,TRIGGER FINGER
Converted from SIS-04/18/2012

Social: He reports that he has quit smoking. he has never used smokeless tobacco. He
reports that he drinks alcohol. He reports that he does not use drugs.

Family: His family history is not on file.

Allergies I Medications

Allergies
Allergies
Allergen Reactions
• Iodine And Iodide Containing Products Rash

Home CV Meds
Medications Prior to Admission
Medication Sig Dispense Refill Last Dose
• bumetanide (BUMEX) 1 MG Take 1 mg by
tablet mouth daily.
• amLODIPine (NORVASC) 5 Take 5 mg by 10/5/2017 at
MG tablet mouth daily. Unknown time
• aspirin 81 MG EC tablet Take 81 mg by 10/5/2017
mouth daily.
• benzonatate (TESSALON) Take 100 mg by 10/6/2017 at
100 MG capsule mouth 3 (three) Unknown time
times daily as
needed for Cough.
• cetirizine (ZYRTEC) 10 MG Take 10 mg by 10/5/2017 at
tablet mouth daily. Unknown time
• clopidogrel (PLAVIX) 75 mg Take 75 mg by 10/4/2017
tablet mouth daily.
• cyanocobalamin 2000 MCG Take 2,500 mcg by 10/5/2017 at
tablet mouth daily. Unknown time
• esomeprazole (NEXIUM) 20 Take 20 mg by 10/6/2017 at
MG capsule mouth daily. Unknown time

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• furosemide (LASIX) 20 MG Take 20 mg by 10/6/2017 at

tablet mouth 2 (two) Unknown time
times daily.
• isosorbide mononitrate TK2 TS PO QD. 3
(IMDUR) 30 MG 24 hr tablet
• metoprolol (LOPRESSOR) Take 25 mg by 10/5/2017 at
25 MG tablet mouth daily. 1200time
• multivit-iron-min-folic acid Take by mouth. 10/5/2017 at
(MULTIVITAMIN-IRON- Unknown time
MINERALS-FOLIC ACID)
3,500-18-0.4 unit-mg-mg
Chew
• pravastatin (PRAVACHOL) Take 40 mg by 10/5/2017 at
20 MG tablet mouth daily . Unknown time
• sucralfate (CARAFATE) 100 Take 1 g by mouth 10/5/2017 at
mg/ml suspension 4 (four) times daily. Unknown time
• UBIDECAR/FISH Take by mouth 10/5/2017 at
OIL/OMEGA-3NITE (CO Omega Q plus 100 Unknown time
Q10-FISH OIL-OMEGA 3-E w/ resveratrol .
ORAL)

Physical Exam

Vitals:
Temp: [97.7 °F (36.5 °C)] 97.7 °F (36.5 °C)
Heart Rate: [74-81] 75
Resp: [18-27] 19
BP: (109-128)/(76-83) 127/80

Gen: Sitting upright

Neck: JVP elevated
Chest wall: No deformity or tenderness
Pulm: Bilateral crackles
CV: RRR, S3, S4
Abd: Soft, non-distended
Ext: Warm, well-perfused, 1+ pitting edema
Pulses: 2+ and symmetric throughout
Neuro: Awake and alert without gross deficits

Labs

CBC
Recent Labs
12/15/18
1458
WBC 9.7
HGB 11.2*
HCT 34.1*
PLT 257

BMP

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Recent Labs
12/15/18
1458
NA 138
K 3.6
CL 96*
CO2 30*
BUN 35*
CREATININE 1.90*
CALCIUM 9.5

Coags
Recent Labs
12/15/18
1458
INR 1.1
PTT 25.9

Cardiac
Recent Labs
12/15/18
1458
BNP 3,001*
TROPONINI 15.77*

Studies

EKG: AVR elevation with some diffuse ST depressions

CXR: Pending

TIE - prior recorded EF 37 % per notes:

Angiography - October 2017

Coronary Anatomy
Coronary Comments
LMCA Calcified, mild plaquing
LAD Proximal occlusion; mid LAD supplied by SVG
Diagonal Filled retrograde from mid LAD
LCx Mild proximal plaque
OM Patent proximal stent; 90% distal stenosis of large OM1
RCA Not injected, known occlusion
SVG-LAD 70% ostial stenosis; 90% stenosis of the SVG-LAD anastomosis

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