allergies: cafergot / prochlorperazine / penicillins / chlorpromazine hcl / prozac attending: chief complaint: dyspnea on exertion major surgical or invasive procedure: mitral valve replacement with a 25 mm biocor tissue valve. tricuspid valve replacement with a 27 mm biocor apical tissue valve. picc placement history of present illness: 49 year old female with history of paroxysmal atrial fibrillation, rheumatic heart disease, hepatitis c, liver fibrosis found to have moderate ms and mild tomoderate mr . she reports symptoms of shortness of breath and chest pain which have gotten progressively worse. she states that she is unable to climb a flight of stairs without stopping 3 times to rest. past medical history: rheumatic heart disease with 2-3+ mr, minimal ms (valve area 1.3 cm2), + tricuspid regurgitation and mild pulmonary hypertension rve/ with ivc dilation by global rv dysfunction ai prior ivda-currently methadone clinic, stopped drugs 1.5 yrs ago etoh abuse-stopped about 1.5 yrs ago atypical chest pain paf-on coumadin last dose chronic anemia hepatitis c c/b liver fibrosis->followed by dr. false positive syphilis test fibromyalgia migraines ibs gerd prior suicide attempt ptsd pleural effusion s/p evacuation bipolar disorder arthritis acid reflux breast lumpectomy endometriosis s/p laparoscopy syncope/fall -approx hypoglycemia cholecystectomy hysterectomy tonsillectomy endometriosis s/p laparoscopy s/p tubal ligation s/p lumpectomy from breast social history: lives with:husband- occupation: unemployed tobacco:1.5ppd x 30 years etoh:none in 1.5 yrs rec drugs: none in 1.5 yrs. h/o ivda and cocaine use in past family history: father died of an mi mother died of heart problems brother died in his 50s from heart problems physical exam: pulse:76 resp:18 o2 sat:99% ra po2 76 on 2l nc b/p right: 113/89 left: height:5'1" weight: 67.3 kg general: nad, alert and cooperative skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur hsm abdomen: soft non-distended non-tender bowel sounds + sl. hepatomegaly extremities: warm , well-perfused edema varicosities: none 2+ pitting edema on bilat. le neuro: grossly intact pulses: femoral right: 2+ left: 2+ dp right: 1+ left: 1+ pt : 1+ left: 1+ radial right: 2+ left: 2+ carotid bruit right: no left: no pertinent results: 05:10am blood wbc-6.5 rbc-3.15* hgb-9.4* hct-27.8* mcv-89 mch-29.8 mchc-33.6 rdw-17.4* plt ct-215 09:00pm blood wbc-5.4 rbc-4.35 hgb-13.1 hct-36.6 mcv-84# mch-30.1 mchc-35.8* rdw-15.8* plt ct-151 12:32pm blood neuts-89.2* lymphs-9.1* monos-1.1* eos-0.5 baso-0.1 05:10am blood plt ct-215 05:10am blood pt-18.1* ptt-28.7 inr(pt)-1.6* 09:00pm blood pt-13.3 ptt-34.7 inr(pt)-1.1 09:00pm blood plt ct-151 05:10am blood glucose-108* urean-42* creat-0.8 na-133 k-3.6 cl-96 hco3-28 angap-13 05:40pm blood glucose-119* urean-50* creat-1.0 na-133 k-4.6 cl-95* hco3-28 angap-15 02:05pm blood urean-8 creat-0.6 na-136 k-4.2 cl-104 hco3-27 angap-9 09:00pm blood glucose-92 urean-9 creat-0.7 na-135 k-4.5 cl-99 hco3-29 angap-12 03:04am blood alt-17 ast-37 ld(ldh)-525* alkphos-67 totbili-1.4 09:00pm blood alt-41* ast-49* ld(ldh)-224 alkphos-87 amylase-66 totbili-0.6 03:29am blood lipase-11 05:10am blood calcium-9.5 phos-3.3 mg-2.4 09:00pm blood %hba1c-5.9 eag-123 05:14am blood osmolal-276 09:23am blood tsh-1.7 09:23am blood t4-9.0 t3-78* 09:23am blood cortsol-36.1* chest two views, findings: two views of the chest compared to prior study from . there is multifocal interstitial and airspace opacification, not appreciably changed from the prior study, could represent a combination of congestive failure or even ards. heart is enlarged. mediastinum is within normal limits. impression: left picc unchanged in superior vena cava. echocardiographic measurements results measurements normal range left atrium - long axis dimension: *4.4 cm <= 4.0 cm left ventricle - septal wall thickness: 1.1 cm 0.6 - 1.1 cm left ventricle - inferolateral thickness: 1.0 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: 4.0 cm <= 5.6 cm left ventricle - systolic dimension: 2.5 cm left ventricle - fractional shortening: 0.38 >= 0.29 left ventricle - ejection fraction: 70% >= 55% left ventricle - lateral peak e': *0.04 m/s > 0.08 m/s left ventricle - septal peak e': *0.03 m/s > 0.08 m/s left ventricle - ratio e/e': *40 < 15 aorta - sinus level: 2.4 cm <= 3.6 cm aortic valve - peak velocity: 1.8 m/sec <= 2.0 m/sec aortic valve - lvot diam: 2.0 cm mitral valve - peak velocity: 1.4 m/sec mitral valve - mean gradient: 6 mm hg mitral valve - e wave: 1.4 m/sec mitral valve - a wave: 0.7 m/sec mitral valve - e/a ratio: 2.00 mitral valve - e wave deceleration time: *400 ms 140-250 ms tr gradient (+ ra = pasp): 7 mm hg <= 25 mm hg findings left atrium: mild la enlargement. left ventricle: normal lv wall thickness, cavity size and regional/global systolic function (lvef >55%). no resting lvot gradient. right ventricle: normal rv free wall thickness. dilated rv cavity. rv function depressed. aorta: normal aortic diameter at the sinus level. mitral valve: bioprosthetic mitral valve prosthesis (mvr). mvr well seated, with normal leaflet/disc motion and transvalvular gradients. tricusid valve: bioprosthetic tricuspid valve (tvr). tvr well seated, with normal leaflet motion and transvalvular gradients. pulmonic valve/pulmonary artery: normal pulmonic valve leaflet. no ps. physiologic pr. normal main pa. no doppler evidence for pda pericardium: no pericardial effusion. general comments: suboptimal image quality - bandages, defibrillator pads or electrodes. conclusions the left atrium is mildly dilated. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef 70%). the right ventricular free wall thickness is normal. the right ventricular cavity is dilated with depressed free wall contractility. a bioprosthetic mitral valve prosthesis is present. the mitral prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. a bioprosthetic tricuspid valve is present. the tricuspid prosthesis appears well seated, with normal leaflet motion and transvalvular gradients. there is no pericardial effusion. compared with the findings of the prior study (images reviewed) of , the mitral and tricuspid valves have been replaced. the right ventricle is somewhat hypocontractile. brief hospital course: admitted for bridge from coumadin with heparin drip. completed preoperative workup and was brought to the operating room and underwent mitral valve and tricuspid valve replacements, see operative report for further details. she was transferred to the intensive care unit for postoperative management. in the first few hours she had significant ventricular ectopy that was treated with amiodarone boluses and drip with improvement however underlying rhythm was complete heart block and continued to be paced with epicardial wires. she remained intubated overnight for hemodynamics and was extubated the morning of postoperative day one. she was started on lasix for diuresis due to pulmonary edema and continued amiodarone. electrophysiology was consulted for rhythm management and she was placed on lidocaine drip with improvement but continued runs on ventricular tachycardia that worsened with activity. pain medications were adjusted, she was weaned off lidocaine and started on betablockers for rhythm management. she continues with ventricular ectopy but no ventricular tachycardia. she was restarted on coumadin for history of pulmonary embolism and atrial fibrillation. she was continued to be diuresed for pulmonary edema, however was noted to have hyponatremia with sodium to 122 with no clear cause that was treated with hypertonic saline and saline tabs and sodium improved however pulmonary edema worsened. her oxygen requirements increased and she continued to require aggressive diuresis and non invasive ventilation for few days. she continued to improve and respiratory status improved. she was transferred to the floor for the remainder of her care. physical therapy worked with her on strength and mobility. she continues on intravenous lasix for diuresis via picc line that she is being discharged to rehab with, and plan for picc removal when no longer requires iv lasix. she was discharged to acute rehab on post operative day 15 to in new . medications on admission: digoxin - 250 mcg tablet - 1 tablet(s) by mouth daily in the pm furosemide - 40 mg tablet - 1 tablet(s) by mouth daily in the pm hydroxyzine hcl 25 mg tablet by mouth twice a day methadone - 40 mg tablet soluble - 1 tablet(s) by mouth daily plus 5mg tablet = 45mg daily dose metoprolol succinate - 25 mg tablet sustained release 24 hr - 1 tablet(s) by mouth daily in the pm potassium chloride - 10 meq tablet sustained release - 1 tablet(s) by mouth daily sertraline - 100 mg tablet in the pm trazodone - 100 mg tablet - tablet(s) by mouth daily at hs warfarin - 7.5 mg tablet - 1 tablet(s) by mouth daily on fridays only, 5mg all other days last dose zolpidem 10 mg tablet - 1 tablet(s) by mouth at bedtime discharge medications: 1. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. ranitidine hcl 150 mg tablet sig: one (1) tablet po once a day. 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. zoloft 100 mg tablet sig: one (1) tablet po once a day. 5. trazodone 100 mg tablet sig: one (1) tablet po hs (at bedtime). 6. hydroxyzine hcl 25 mg tablet sig: one (1) tablet po bid (2 times a day). 7. spironolactone 25 mg tablet sig: one (1) tablet po daily (daily). 8. methadone 40 mg tablet, soluble sig: one (1) tablet, soluble po daily (daily): total dose 45 mg . 9. methadone 5 mg tablet sig: one (1) tablet po once a day: total dose 45 mg daily . 10. ipratropium-albuterol 18-103 mcg/actuation aerosol sig: four (4) puff inhalation q6h (every 6 hours). 11. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 12. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 13. guaifenesin 600 mg tablet extended release sig: two (2) tablet extended release po bid () for 2 days. 14. magnesium oxide 400 mg tablet sig: one (1) tablet po daily (daily). 15. picc line sodium chloride 0.9% flush 10 ml iv prn line flush picc, non-heparin dependent: flush with 10 ml normal saline daily and prn per lumen. remove picc line when no longer on intravenous lasix 16. potassium chloride 20 meq tablet, er particles/crystals sig: two (2) tablet, er particles/crystals po twice a day for 3 days: then decrease to 40 meq daily with iv lasix . 17. furosemide 10 mg/ml solution sig: eighty (80) mg injection daily (daily) for 3 days: then decrease to 40 mg iv daily . 18. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: three (3) ml inhalation every four (4) hours as needed for shortness of breath or wheezing. 19. methadone clinic methadone clnic in , . phone # . open from 6am to 1015am daily has received 45 mg daily while in the hospital 20. coumadin and inr coumadin 7.5 mg inr 1.6 coumadin 4 mg inr 1.8 coumadin 5 mg inr 1.9 coumadin 2.5mg inr 2.2 coumadin 4 mg inr 2.6 coumadin 2.5mg inr 2.7 coumadin 2.5mg inr 3.1 coumadn 3mg inr 2.2 coumadin 5 mg inr 1.9 coumadin 5 mg inr 1.5 coumadin 5 mg inr 1.4 nutriton had been poored and now improved with shakes (ensure) which contain vitamin k home doses prior to admission 5-7.5 mg daily 21. outpatient lab work labs: pt/inr for coumadin ?????? indication atrial fibrillation and pulmonary embolism goal inr first draw wendesday physician at rehab to monitor inr and dose coumadin based on results - please check monday and wednesday and friday for 3 weeks to maintain close monitoring due to liver disease and then twice a week please arrange for coumadin management with pcp prior to discharge from rehab 22. outpatient lab work chem 10 twice a week while on iv lasix 23. warfarin 5 mg tablet sig: goal inr 2.0-3.0 tablets po once a day: dose based on inr by rehab physician draw for further dosing . discharge disposition: extended care facility: discharge diagnosis: mitral regurgitation s/p mnr tricuspid regurgitation s/p tvr ventricular trachycardia respiratory failure rheumatic heart disease hypertension right ventricular failure prior ivda-currently on methadone etoh abuse-stopped about 1.5 yrs ago atypical chest pain paroxysmal atrial fibrillation chronic anemia hepatitis c liver fibrosis fibromyalgia migraines irritable bowel syndrome gastric esophageal reflux disease post traumatic stress disorder pleural effusion bipolar disorder arthritis breast lumpectomy endometriosis s/p laparoscopy syncope/fall -approx hypoglycemia cholecystectomy hysterectomy tonsillectomy discharge condition: alert and oriented x3 nonfocal ambulating with 1 assist incisional pain managed with tylenol prn continues on methadone 45 mg as prior to admission incisions: sternal - healing well, no erythema or drainage edema +1 bilateral le 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 1:00 cardiologist: dr - cardiac surgery office to contact you with appointment liver: dr 11:00 please call to schedule appointments with your primary in weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** labs: pt/inr for coumadin ?????? indication atrial fibrillation and pulmonary embolism goal inr first draw wendesday physician at rehab to monitor inr and dose coumadin based on results - please check monday and wednesday and friday for 3 weeks to maintain close monitoring due to liver disease and then twice a week please arrange for coumadin management with pcp prior to discharge from rehab Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of mitral valve with tissue graft Open and other replacement of tricuspid valve with tissue graft Central venous catheter placement with guidance Diagnoses: Anemia, unspecified Esophageal reflux Tobacco use disorder Acute posthemorrhagic anemia Alcoholic cirrhosis of liver Hyposmolality and/or hyponatremia Other and unspecified alcohol dependence, in remission Unspecified viral hepatitis C without hepatic coma Atrial fibrillation Other chronic pulmonary heart diseases Paroxysmal ventricular tachycardia Acute respiratory failure Atrioventricular block, complete Long-term (current) use of other medications Long-term (current) use of anticoagulants Personal history of venous thrombosis and embolism Bipolar disorder, unspecified Myalgia and myositis, unspecified Diseases of tricuspid valve Rheumatic mitral insufficiency Irritable bowel syndrome Posttraumatic stress disorder Opioid type dependence, in remission Cocaine dependence, in remission