NFRMC Discharge Summary 10-04-12 to 10-06-12

Discharge Summary Note

Discharge Summaries Signed by Samraj, George MD 10/08/12 4:45 PM

I saw and evaluated Diane Betes 67 yo female
I evaluated the notes and H & P. Reviewed the vitals labs and radiology before discharge.Verified the findings in the notes and rounded with the resident on the day of discharge. I discussed the finding and care with the resident and agree with resident's findings and plan as documented in the note. Discharge plans reviewed and discussed.
Discharge Summaries Signed by Smith, John MD (resident) 10/06/12 3:34 PM Admit date: 10/04/12 Discharge date: 10/06/12 12:25 PM Admitting Physician: George Samraj, MD Discharge Physician: Samraj, George Admission Diagnoses: Acute HF Discharge Diagnoses: AcuteHF , ShOB, A. Fibrillation Hospital Problems: Acute HF (chronic heart failure)
Atrial Fibrillation
Type 2 diabetes mellitus without mention of complication, uncontrolled
HTN (hypertension)
Hyperlipidemia
Osteoarthritis
COPD (chronic obstructive pulmonary disease)
HFpEF Discharged Condition: stable ED vitals 10/4/12: BP: 192/100 mmHg, pulse: 125, RR: 27 Sp02: 83% on RA Weight: 206 lbs (93.6 kg) Ht: 5’6" Physical Exam:
General: Overweight female, appears in respiratory distress, sweaty seated upright. Cardiovascular: S1, S2 and S4 heard, irregular with no m/g/r and no JVD. Pulmonary: fine crackles 2/3 up in lung fields posteriorly. Abdomen: unremarkable. Extremities: No peripheral edema, peripheral pulses palpable.
Hospital Course: 67 y.o. female w/ a PMH of HTN, DM type 2 on basal-bolus insulin, hyperlipidemia, osteoarthritis, COPD, tobacco abuse, and atrial fibrillation. Presented to the ED with acute onset shortness of breath started 6 hours before arrival. Just prior to the episode she felt like her heart was racing. She was anxious, admitted some previous dyspnea on exertion but related it to her COPD/continued smoking, denies lower extremity swelling or abdominal distension. She had been feeling well the day prior.
She was treated for heart failure with preserved EF 2/2 AF that spontaneously converted to NSR in ED. She was treated with loop diuretics. Her BNP was elevated, She had a normal CBC, CMP and cardiac enzymes were not elevated. CXR was c/w pulm edema. By the time she left ED she was on 2l NC with pulse Ox of 99%. She was admitted and observed on the general medicine ward for 24 more hours and stabilized in NSR HR 75-80 BP 140-150/80-90 RR 16 on RA. Patient was strongly advised to quit smoking and received nicotine patches during the hospital admission. Home medications were continued and other disease states stable.
She will be discharged home and will follow-up with her primary care physician, Dr. Banner in 1 to 2 weeks.

Laboratory Findings Date

Lab Result Range & Units 10/04/12 1:25 PM NT PRO BNP 328 (H) <125 pg/ml 10/04/12 1:25 PM WBC 5.6 3.8-10.8 Thousand/uL RBC 4.25 3.80-5.10 Million/uL Hemoglobin 12.5 11.7-15.5 g/dL Hematocrit 38.0 35.0-45.0% MCV 89.3 80.0-100.0 fL MCH 29.4 27.0-33.0 pg MCHC 32.9 32.0-36.0 g/dL RDW-CV 14.8 11.0-15.0% Platelets 190 140-400 Thousand/uL 10/04/12 1:25 PM Glucose 136 (H) 65-99 mg/dl Urea Nitrogen 17 7-25 mg/dl Creatinine 0.65 0.50-0.99 mg/dL BUN/Creatinine Ratio NOT APPLICABLE 6-22 (calc) Sodium 141 135-146 mmol/L Potassium 3.9 3.5-5.3 mmol/L Chloride 105 98-110 mmol/L Carbon Dioxide 26 21-33 mmol/L Calcium 9.3 8.6-10.4 mg/dL Protein Total 6.4 6.2-8.3 g/dL
Test: Echo Collected Date & Time: 10/04/12 2:34 PM
Patient Name: Diane Betes
MRN Number: 123456
Procedure Date: 10/04/12
IP/OP Status: Inpatient
Patient Location: Room 34, Bed A
Ordering Physician: GEORGE SAMRAJ, M.D.
Sonographer: Pam Schien Height: 66 in
Tape: / 00:00:00 DOB: 03/03/1945 Gender: Female Weight: 206lbs
Procedure: Transthoracic echocardiogram; M-Mode, 2D, Doppler, Color Doppler, and Tissue Doppler examination
Conditions: Chronic Heart Failure Unspecified
Conclusions:
1. Study Quality-Adequate
2. Normal left ventricular size. Severe left concentric ventricular hypertrophy. Normal left ventricular function. End systolic cavity obliteration. No SAM. Peak left ventricular outflow tract gradient equals 3.5 mmHg, mean gradient equals 2 mmHg. All segments contract normally. Left ventricular ejection 55-60%
3. Marked left atrial enlargement. Mild right atrial enlargement.
4. Findings are consistent with aortic sclerosis
5. Mild mitral regurgitation
6. the LV diastolic function is abnormal. E/E’=23 suggestive of elevated LV filling pressures
7. No prior study for comparision.
2D Measurements
Dimensions: (cm) Normal Value:
Value:
LVOT: 1.9 cm
LA Volume: 99 ml
IVS (ed): 1.9 cm 0.7-1.1
LVPW (ed): 1.9 cm
LA (es): 5.1 cm 1.6-4
Aortic Root: 3.2 cm 2-3.7
LVID (ed): 3.9 cm 3.8-5.6
2 Dimensional Findings
Study Quality: Adequate
LV Function: normal left ventricular function. End systolic cavity obliteration. No SAM
LV Size/Thickness: Normal left ventricular size. Severe left concentric ventricular hypertrophy
Wall Motion: All segments contract normally
Right ventricle: Normal right ventricular size and function
Left Atrium: Marked left atrial enlargement
Right Atrium: Mild right atrial enlargement
Aorta: Normal aorta, normal aortic arch
Pulmonary Artery: Normal pulmonary artery
Aortic valve: aortic sclerosis noted
Mitral valve: Normal mitral valve
Tricuspid valve: Normal tricuspid valve
Pulmonic valve: Normal pulmonic valve
Pericardium: Normal pericardium
Doppler Findings:
Aortic sclerosis noted, Mild mitral regurgitation. Minimal tricuspid regurgitation. Minimal pulmonic regurgitation. Peak left ventricular outflow tract gradient equals 3.5 mmHg, mean gradient equals 2 mmHg. The LV diastolic function is abnormal. E/E’=23 suggestive of elevated LV filling pressures. Interpreting physician:
JOHN SMITH, M.D.
Thos document was electronically signed by JOHN SMITH, M.D., on Date: 10/05/12 10:11 AM