allergies: lisinopril / ampicillin attending: chief complaint: dyspnea on exertion, fatigue major surgical or invasive procedure: aortic valve replacement(21mm st. epic porcine) history of present illness: this is a 76 year old female with aortic stenosis has been experiencing progressive symptoms of exertional chest pressure that occurs when walking up an incline and overall activity intolerance. she also notes dysnea when climbing stairs. she does report having dizzy spells back in and was started on meclizine by her pcp with improvement. she denies any recent syncope but did have syncope in prior to her pacemaker being placed. her most recent echo which was done in demonstrates severe aortic stenosis. she was recently seen by dr. who referred her for cardiac catheterization. she underwent cardiac cath on which revealed clean coronaries. she was cleared to proceed with surgery and admitted to cardiac surgery for an aortic valve replacement. prior to surgery, coumadin was stopped five days prior and she was admitted the day before for intravenous heparin. past medical history: severe aortic stenosis hypertension retinal tear without detachment hammer toe atrial fibrillation - on coumadin diabetes type i diagnosed at age 32 history of syncope last episode pacemaker - :5826 / serial: s/p right knee replacement surgery s/p right hip replacement surgery s/p right foot surgery s/p bilateral vein stripping s/p right tennis elbow surgery social history: last dental exam: 1 month ago, dentist gave verbal clearance, general written clearance in chart lives with: daughter contact: (daughter) phone # occupation: retired cigarettes: smoked no yes other tobacco use: denies etoh: < 1 drink/week drinks/week >8 drinks/week illicit drug use: denies family history: denies premature coronary artery disease. father had an mi in his 70s. physical exam: preop exam - height:5'8" weight:170 lbs vitals: pulse:59 resp:20 o2 sat:100% ra bp right:141/60 left:142/60 general: awake, alert, no acute distress skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur grade _iii_ abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema 2+ edema in r lower extremity 1+ left lower extremity edema varicosities: none (s/p ble vein stripping) neuro: grossly intact pulses: femoral right: 2+ left: 2+ dp right: trace left: trace pt : trace left: trace radial right: 2+ left: 2+ carotid bruit right: none left: none pertinent results: 06:25am blood wbc-8.9 rbc-3.24* hgb-9.5* hct-28.4* mcv-88 mch-29.5 mchc-33.6 rdw-13.9 plt ct-105* 05:55am blood pt-26.9* inr(pt)-2.6* 06:25am blood glucose-141* urean-21* creat-0.8 na-136 k-3.9 cl-100 hco3-28 angap-12 06:25am blood mg-2.0 pcxr: impression: ap chest compared to : previous mild pulmonary edema has almost entirely cleared. bibasilar atelectasis, moderate on the left, unchanged, moderate on the right, increased slightly, accompanied by new small right pleural effusion. postoperative cardiomediastinal silhouette is unremarkable and unchanged. small right pneumothorax is new. there is no pneumothorax on the left. transvenous right atrial and right ventricular pacer leads in standard placement. dr. approved: fri 4:07 pm tee: pre-bypass: the left atrial appendage emptying velocity is depressed (<0.2m/s). a patent foramen ovale is present. a left-to-right shunt across the interatrial septum is seen at rest. the left ventricle is not well seen. right ventricular chamber size and free wall motion are normal. there are simple atheroma in the aortic arch. there are simple atheroma in the descending thoracic aorta. the aortic valve is bicuspid. the aortic valve leaflets are severely thickened/deformed. there is severe aortic valve stenosis (valve area 0.8-1.0cm2). mild to moderate (+) aortic regurgitation is seen. the mitral valve leaflets are severely thickened/deformed. there is severe mitral annular calcification. there is moderate valvular mitral stenosis (area 1.0-1.5cm2). no mitral regurgitation is seen. there is no pericardial effusion. dr. was notified in person of the results at time of surgery. post-bypass: there is a bioprosthetic valve in the aortic position. the valve appears well seated with normally mobile leaflets. no paravalvular leaks are seen. there is no ai. the left ventricular systolic function appears normal, estimated ef=55%. the right ventricular systolic function appears normal. there is no evidence of dissection. brief hospital course: mrs. was admitted for intravenous heparin and routine preadmission testing. workup was uneventful and she was cleared for surgery. the following day, she underwent an aortic valve replacement by dr. a 21mm st. porcine valve. for surgical details, please see operative note. given her severe penicillin allergy, vancomycin was used for perioperative antibiotic coverage. following the operation, she was brought to the cvicu for invasive monitoring. within 24 hours, she awoke neurologically intact and was extubated without incident. initially hypotensive, she required phenylephrine drip. she was also transfused with prbc for a postoperative anemia, and ep increased her pacemaker rate to 70 bpm. over several days, her hemodynamics improved. she transiently required insulin drip for adequate glucose control. on postoperative day two, she transferred to the sdu. warfarin was resumed and dosed for a goal inr between 2.5 to 3.0. on the floor she continued to progress well. pacing wires and ct were discontinued without incident. she was hyperglycemic at times and insulin was adjusted. her post-operative cxr revealed small right pneumo that was stable and unchanged on her discharge cxr. all patients questions and concerns addressed. follow up appts made. she was discharged to health care rehab on pod #4. medications on admission: atenolol 100 mg atorvastatin 10 mg daily insulin lispro 100 unit/ml solution - sliding scale with meals losartan 100 mg daily potassium chloride 10 meq daily triamterene-hydrochlorothiazid 37.5 mg/25 mg capsule - 1 capsule daily warfarin 1 mg tablet - 1-2 tablets by mouth 1mg m/f, 2mg all other days last dose wed magnesium oxide 400 mg daily nph insulin human recomb 100 unit/ml suspension - 42 units in the am discharge medications: 1. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 2. potassium chloride 10 meq tablet extended release sig: two (2) tablet extended release po q12h (every 12 hours) for 10 days: then reevaluate. tablet extended release(s) 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 5. warfarin 1 mg tablet sig: as directed tablet po daily (daily). 6. acetaminophen 325 mg tablet sig: two (2) tablet po every six (6) hours as needed for pain/fever: prn for pain. tablet(s) 7. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed for constipation. 8. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 9. tramadol 50 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. disp:*40 tablet(s)* refills:*0* 10. magnesium oxide 400 mg tablet sig: one (1) tablet po daily (daily). 11. furosemide 10 mg/ml solution sig: two (2) ml injection q12h (every 12 hours) for 10 days: then reevaluate. 12. nph insulin human recomb 100 unit/ml suspension sig: forty two (42) units subcutaneous once a day: give in am. 13. novolog 100 unit/ml solution sig: achs units subcutaneous sliding scale: see sliding scale attached. 14. losartan 25 mg tablet sig: one (1) tablet po once a day. discharge disposition: extended care facility: health care center - discharge diagnosis: aortic stenosis s/p aortic valve replacement( tissue) paroxysmal atrial fibrillation s/p permanent pacemaker implant (st. 5826 in ) hypertension s/p bilateral vein strippings insulin dependent diabetes mellitus postop anemia discharge condition: alert and oriented x3, nonfocal ambulating with assist incisional pain managed with incisions: sternal - healing well, no erythema or drainage edema +2 right lower, +1 left lower discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns females: please wear bra to reduce pulling on incision, avoid rubbing on lower edge **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments: surgeon: dr.() on at 1;15pm cardiologist: dr. no 3/19/12/at11;10am please call to schedule appointments: primary care: dr. (in weeks inr goal 2.5-3.0 for a-fib coumadin to be managed by her pcp **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hour Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve with tissue graft Artificial pacemaker rate check Diagnoses: Other iatrogenic hypotension Anemia, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Atrial fibrillation Aortic valve disorders Long-term (current) use of insulin Long-term (current) use of anticoagulants Knee joint replacement Fitting and adjustment of cardiac pacemaker Hip joint replacement Other pneumothorax