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CASE STUDY

ST. ROSE SAN MARTIN

IRIS SOLIVEN

March 2018

Patient Information

46 year old male with chest pain who presented for evaluation of worsening dyspnea for 2-3 weeks. He reports driving back from Indiana last week for 3 days and since then both his legs got very swollen. "

PATIENT INFO

History:

hypertension, gunshot wound, cerebrovascular accident

Diagnosis

Diagnosis

Congestive heart failure, severe mitral valve regurgitation, nonischemic cardiomyopathy with estimated ejection fraction of 5-10%

CONGESTIVE HEART FAILURE

CONGESTIVE HEART FAILURE

Congestive Heart Failure is a condition in which the heart's function as a pump is inadequate to meet the body's needs.

Cardiogenic Pulmonary Edema

This occurs when the left ventricle is unable to pump out a sufficient amount of blood during each ventricular contraction.

SIGNS & SYMPTOMS

Tachypnea, Tachycardia, increased blood pressure, Cheyne-Stokes, cyanosis, pink-frothy secretions, increased tactile fremitus, crackles and wheezing

SURGERY

PLAN

TEE

TRANSESOPHAGEAL ECHOCARDIOGRAM

Transesophageal echocardiography (TEE) is a test that produces pictures of your heart. TEE uses high-frequency sound waves (ultrasound) to make detailed pictures of your heart and the arteries that lead to and from it.

1. Severe mitral regurgitation with some improvement with dobutamine infusion consistent with good contractile reserve and dilated cardiomyopathy secondary to mitral regurgitation.

2. Normal RV chamber size

3. Aortic valve appears intact. Mild tricuspid regurgitation.

Physician Notes

3/15

" patient underwent left and right heart cathertization by Dr today. No significant coronary disease. Moderate pulmonary hypertension. Patient now is willing to prceed for surgical intervention to help him. Talk with patient regarding weak heart w/ EF about 20% and possibilities of post of complication, long ICU stay, and need for intra-aortic balloon pump.

Update 1

SURGERY

SURGERY

Mitral valve replacement surgery with post-op intaaortic balloon pump.

Procedure:

1. Mitral valve replacement using tissue valve since you epic valve size 33 mm. With leaflet preservation as well as chordee technique.

2. Ligation left atrial appendage using Atricure clip

3. Mideastinal lumph node biopsy level R4

4. Placement of intra-aortic balloon pump Pre-op.

PHYSICIAN NOTES

3/17

“Diagnosis

-status post mitral valve replacement

hx non ischemic cardiomyopathy

-cardiogenic shock, low EF post op, 10-15%

-AKI

Plan

-Mechanical Ventilation, coordinate extubation with anesthesia

aggressive pulmonary hygiene post extubation

pressors, inotropes, IABP, pacing wires, chest tubes – CV surgery managing

Blood sugar control

electrolytes replacement

PUD prophylaxis

DVT prophylaxis

Pain control

Physician Notes

3/20

Patient is extubated, awake aleart oriented, status post AIBP balloon was discon. Yesterday still low doses of epi. Status post bronchoscopy. T-max 38.6 current temperature same

all cultures are negative

sternal wound clean

lab results were discussed with patient discussed

Now extubated on NC, no acute distress, PA pressures noted PAS 60s on Milrinone drip, not ready to wean today wean Epi as tolerated.

noted HGB: 7.8 given that HR is good BP is good, being diuresed will hold off transfuse for now.

Chest tube output 70cc/24 hour. Consider remove today.

Physician Notes

Physician Notes

Update 2

LABS

LABS

CBC

CBC

CHEMISTRY

BLOOD GASES

X-RAY

“Findings: indwelling swanz-ganz catheter indwelling IJ SVC sheath. Mediastinal chest tubes present. Cardiomegaly. Perihilar and bisalar infiltration. ETT above carina. Indwelling atrial appendage done.

Impression: support lines and tubes in good position. Perihilar and basilar subsegmental atelectasis. Small bilateral pleural effusion.

X-RAYS

New hire

New hire

Name, Department

Start date

New hire

New hire

Name, Department

Start date

Special dates

NAME

Birthday

Department

NAME

Years with company

Department

What's next

Timeline

MEDICATION

January

March

February

Keep in mind

Keep in mind

Changes

Changes

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