allergies: patient recorded as having no known allergies to drugs attending: chief complaint: type a aortic dissection major surgical or invasive procedure: graft replacement ascending aorta & resuspension of aortic valve history of present illness: this 78 year old male presented to ed with the acute onset of severe tearing pain in the upper back and left arm in the ed the arm was cold, obviously ischemic and his sysytolic bp was greater than 200. a cta demonstated a type a dissection. he was intubated and labetolol and nicardipine infusions were begun. he was air transported to for surgical treatment. past medical history: hypertension hyperlipidemia social history: lives alone non smoker/drinker family history: non-contributory physical exam: admission: pulse: 60s in sr resp: cmv 100% 550 x 16 o2 sat: 96% b/p right: left: height: weight: general: skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur iv/vi hsm at base abdomen: soft non-distended non-tender bowel sounds extremities: warm , well-perfused lue cold, mottled neuro: gcs 3t pulses: femoral right: 2+ left: 2+ dp right: 2+ left: 2+ pt : 2+ left: 2+ radial right: 2+ left: absent carotid bruit right: (-) left: (-) pertinent results: 05:10am blood wbc-9.0 rbc-3.20* hgb-9.0* hct-27.5* mcv-86 mch-28.2 mchc-32.8 rdw-13.5 plt ct-224 01:28am blood wbc-11.6* rbc-3.50* hgb-10.1* hct-30.6* mcv-88 mch-28.9 mchc-33.1 rdw-14.0 plt ct-168 05:20am blood pt-12.9 inr(pt)-1.1 05:10am blood pt-12.4 ptt-21.9* inr(pt)-1.0 05:20am blood urean-37* creat-1.0 k-3.9 05:10am blood glucose-105* urean-35* creat-1.2 na-143 k-3.9 cl-109* hco3-27 angap-11 01:28am blood glucose-92 urean-40* creat-1.3* na-145 k-3.7 cl-110* hco3-26 angap-13 04:19am blood wbc-5.5 rbc-3.21* hgb-9.1* hct-26.8* mcv-84 mch-28.3 mchc-33.8 rdw-13.9 plt ct-181 05:10am blood wbc-9.0 rbc-3.20* hgb-9.0* hct-27.5* mcv-86 mch-28.2 mchc-32.8 rdw-13.5 plt ct-224 04:18am blood pt-14.5* ptt-34.0 inr(pt)-1.3* 05:10am blood pt-12.4 ptt-21.9* inr(pt)-1.0 05:05am blood glucose-121* urean-29* creat-1.3* na-144 k-4.4 cl-112* hco3-24 angap-12 05:10am blood glucose-105* urean-35* creat-1.2 na-143 k-3.9 cl-109* hco3-27 angap-11 echocardiography report eu critical, (complete) done at 1:53:51 am final referring physician information , r. , division of cardiothorac , status: inpatient dob: age (years): 78 m hgt (in): bp (mm hg): / wgt (lb): hr (bpm): bsa (m2): indication: type a dissection. note: patient's name is . icd-9 codes: 786.51, 441.00, 424.1, 424.0 test information date/time: at 01:53 interpret md: , md test type: tee (complete) son: , md doppler: full doppler and color doppler test location: anesthesia west or cardiac contrast: none tech quality: adequate tape #: 2010aw1-: machine: echocardiographic measurements results measurements normal range left ventricle - ejection fraction: 50% to 55% >= 55% aorta - ascending: *5.2 cm <= 3.4 cm findings left atrium: no spontaneous echo contrast is seen in the laa. right atrium/interatrial septum: normal interatrial septum. left ventricle: low normal lvef. right ventricle: normal rv chamber size and free wall motion. aorta: ascending aortic intimal flap/dissection.. aortic arch intimal flap/dissection. descending aorta intimal flap/aortic dissection. aortic valve: mildly thickened aortic valve leaflets (3). moderate to severe (3+) ar. mitral valve: mildly thickened mitral valve leaflets. mild (1+) mr. tricuspid valve: physiologic tr. pericardium: no pericardial effusion. general comments: a tee was performed in the location listed above. i certify i was present in compliance with hcfa regulations. the patient was under general anesthesia throughout the procedure. the tee probe was passed with assistance from the anesthesioology staff using a laryngoscope. no tee related complications. conclusions pre-cpb: this is a directed study in an emergency case with a type a dissection. no spontaneous echo contrast is seen in the left atrial appendage. overall left ventricular systolic function is low normal (lvef 50-55%). right ventricular chamber size and free wall motion are normal. a mobile density is seen in the ascending aorta, the aortic arch and the descending aorta consistent with an intimal flap/aortic dissection. the aortic valve leaflets (3) are mildly thickened. moderate to severe (3+) aortic regurgitation is seen. there is an intact stj. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is no pericardial effusion. post-cpb: the patient is on a phenylephrine drip and is av-paced. there is a prosthetic ascending aorta. there is trace - 1+ ai. trace mr. systolic fxn. other parameters as pre-bypass. i certify that i was present for this procedure in compliance with hcfa regulations. electronically signed by , md, interpreting physician 04:23 ?????? caregroup is. all rights reserved. brief hospital course: following transfer mr. was taken emergently to the operating room where the dissection was repaired with a #28mm gelweave tube graft and the valve resuspended (see operative note for details). he tolerated the procedure well and weaned from bypass on neo synephrine, propofol and insulin infusions. he remained stable and was kept intubated the day after surgery. pressors were weaned off, he awoke intact and was extubated on pod 2. he was diuresed and after some initial confusion was neurologically intact by pod 3. cts were removed according to protocol and beta blockade and ace inhibitors begun for blood pressure control. his rhythm went into rate controlled atrial fibrillation on and he was treated with amiodarone and beta-blocker. he was transferred to the floor on pod 3, pacing wires were discontinued per protocol and physical therapy worked with him for mobilization and strength. pod#4 anticoagulation with coumadin was initiated for atrial fibrillation. he continued to progress and was cleared for discharge to rehab on pod# 5. all follow up appointments were advised. medications on admission: allopurinol, flomax discharge medications: 1. allopurinol 300 mg tablet sig: 0.5 tablet po daily (daily). 2. tamsulosin 0.4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po hs (at bedtime). 3. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 4. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). 5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 6. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 7. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain. 8. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. 9. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed for constipation. 10. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po q12h (every 12 hours). 11. furosemide 20 mg tablet sig: two (2) tablet po q12h (every 12 hours) for 10 days. disp:*40 tablet(s)* refills:*0* 12. amiodarone 200 mg tablet sig: two (2) tablet po bid (2 times a day): 400mg x 2 weeks, then 200mg x 2 weeks, then 200mg daily until further instructed. tablet(s) 13. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 14. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed for wheezes. 15. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours) as needed for wheezing. 16. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 17. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 18. warfarin 5 mg tablet sig: one (1) tablet po once a day: dose to change daily for goal inr 2-2.5. tablet(s) 19. outpatient lab work serial pt/inr dx: atrial fibrillation goal inr 2-2.5 20. lisinopril 10 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* discharge disposition: extended care facility: tba discharge diagnosis: type a aortic dissection hyperlipidemia hypertension discharge condition: discharge condition: alert and oriented x3 nonfocal ambulating, gait steady sternal pain managed with tylenol prn discharge instructions: discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions 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 until follow up with surgeon no lifting more than 10 pounds for 10 weeks please call with any questions or concerns followup instructions: dr. appointment arranged for , at 1pm dr. in weeks () dr. to follow coumadin on discharge from rehab dr. (cardiolotist, ) 3pm wound check appointment - 6 () - your nurse will schedule provider: , md phone: date/time: 1:00 Procedure: Extracorporeal circulation auxiliary to open heart surgery Diagnostic ultrasound of heart Cardioplegia Resection of vessel with replacement, thoracic vessels Transfusion of packed cells Open heart valvuloplasty of aortic valve without replacement Diagnoses: Anemia, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Atherosclerosis of aorta Atrial fibrillation Aortic valve disorders Other and unspecified hyperlipidemia Dissection of aorta, thoracic