allergies: sulfa (sulfonamide antibiotics) / latex / neomycin / nickel sulfate / metabisulfites attending: chief complaint: asymptomatic aortic aneurysm major surgical or invasive procedure: l thoracotomy/ repair thoracoabdominal aortic aneurysm (32 mm x 8mm gelweave graft) re-exploration for hemothorax history of present illness: 74 year old female who has been followed with serial ct scans x many years for a known descending thoracic aneurysm. most recent scan shows progression of aortic size and surgery was recommmended. she is not a candidate for endo-stent grafting. past medical history: hypertension thoracoabdominal aortic aneurysm glaucoma vaginal prolapse stress incontinence gastroesophageal reflux disease hypothyroidism eczema bullous pemphigoid (currently on prednisone) past surgical history: s/p hysterectomy, bladder suspension and rectocele in , and also another bladder suspension in s/p appendectomy s/p tonsillectomy social history: lives with: husband in , ma occupation: retired tobacco: she quit smoking approximately 30 to 40 years ago. etoh: rare use family history: father with cabg in his 70's physical exam: height: 62" weight: 165 lb general: well-developed female in no acute distress skin: dry intact healing lesions throughout heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema: - varicosities: b/l neuro: grossly intact pulses: femoral right: 2+ left: 2+ dp right: 2+ left: 2+ pt : 2+ left: 2+ radial right: 2+ left: 2+ carotid bruit right: - left: - pertinent results: tte conclusions: there is mild symmetric left ventricular hypertrophy. overall left ventricular systolic function is normal (lvef>75%). with normal free wall contractility. the aortic valve leaflets (3) are mildly thickened. no masses or vegetations are seen on the aortic valve. mild (1+) aortic regurgitation is seen. no mitral regurgitation is seen. there is no pericardial effusion. preliminary report developed by a cardiology fellow. not reviewed/approved by the attending echo physician. . was notified in person of the results . interpretation assigned to , md, interpreting physician : brain mri: there are multiple areas of restricted diffusion seen predominantly in the left cerebral hemisphere in the subcortical region, but also in the right basal ganglia region indicative of acute infarcts, likely embolic. there is mild-to-moderate brain atrophy and small vessel disease seen. no evidence of midline shift or hydrocephalus identified. impression: multiple small acute infarcts in the basal ganglia and subcortical region of the left cerebral hemisphere as well as in the right basal ganglia region. no mass effect or hydrocephalus. small acute infarct is also seen in the right cerebellum. mra head: the head mra demonstrates no evidence of vascular occlusion of the major arterial structures of the anterior and posterior circulation. impression: no significant abnormalities on mra of the head. 04:49am blood wbc-11.5* rbc-3.17* hgb-10.0* hct-29.5* mcv-93 mch-31.5 mchc-33.9 rdw-16.6* plt ct-242 04:49am blood glucose-123* urean-38* creat-0.9 na-145 k-3.9 cl-107 hco3-35* angap-7* brief hospital course: ms. was admitted on and underwent open repair of thoracoabdominal aortic aneurysm from left subclavian to celiac (known descending aortic aneurysm)with dr. and dr. . she underwent dhca of 27mins. she transferred to the cvicu in fair condition on levophed and propofol with a lumbar drain in place. she returned to the operating room for bleeding and control was achieved. see intraoperative note for further details. she arrived to the unit the second time on neosynepherine and remained on amiodarone for nsvt. she became hypotensive but a bedside tte was unremarkable. she was awoken for neuro evaluation and was noted not to be moving her lower extremities. seizure activity was noted on pod #2 and neurology was consulted. a ct of the head showed l thalamic acute stroke while her exam revealed rle paresis. an mri of the brain noted multiple small acute infarcts as well as a small r cerebellar infarct and t11 infarct. she was started on keppra. she was bronched on pod#2 for lll collapse and hypoxemia. propofol was eventually discontinued and she extubated without difficulty on pod#4 pressor support was slowly weaned off. she was started on emperic vancomycin and zosyn for leukocytosis. she also became thrombocytopenic but was hit negative and her plts eventually recovered. her lumbar drain was eventually removed without difficulty. she continued to have episodes of nsvt and she continued on amiodarone taper. she continued to make improvement neurologically. she failed her speech and swallow exam and was started on tube feeds. she also had continued hoarse voice. on pod#7 she transferred to the floor. she was seen by orl and was found to have hypomobility of left vocal cord and may benefit from injection if it does not improve. should this be the case, she should follow-up with dr. from orl. she continued to progress and was advanced to pureed solids and nectar thick fluids and pills crushed in apple sauce after passing a speech and swallow exam. she continued with tube feeds at night of two cal hn full strength with 7gm/day of beneprotein at a rate of 30 ml/hr via her dobhoff tube until her nutritional needs are adequately met orally. her oral intake will likely be sufficient over the next couple of days to warrant cessation of tube feeds. the neurology service saw her a few days before discharge and felt that she is making neurological recovery and should continue to do so. they recommended continuing keppra, maintaining a map of around 100, and following up with dr. in weeks. her former chest tube site drains copious serosanguinous fluid and requires frequent gauze dressing changes to keep the site dry. although macerated from fluid, the site does not look infected. by post-operative day nine she was ready for discharge to . all follow-up appointments were advised. medications on admission: clobetasol - (prescribed by other provider) - 0.05 % cream - ointment twice a day estradiol - (prescribed by other provider) - 25 mcg tablet - 2x/wk folic acid - (prescribed by other provider) - 1 mg tablet - 1 (one) tablet(s) by mouth once a day irbesartan - (prescribed by other provider) - 150 mg tablet - 1 tablet(s) by mouth once a day latanoprost - (prescribed by other provider) - 0.005 % drops - 1 (one) once a day levothyroxine - (prescribed by other provider) - 100 mcg tablet - 1 (one) tablet(s) by mouth once a day omeprazole - (prescribed by other provider) - 20 mg capsule, delayed release(e.c.) - 1 (one) capsule(s) by mouth once a day timolol - (prescribed by other provider) - 0.25 % drops - 1 (one) once a day verapamil - (prescribed by other provider) - 180 mg cap,24 hr sust release pellets - 1 (one) cap(s) by mouth once a day medications - otc aspirin - (prescribed by other provider) - 81 mg tablet, chewable - 1 (one) tablet(s) by mouth once a day multivitamin - (prescribed by other provider) - tablet - 1 tablet(s) by mouth once a day vit c-vit e-copper-znox-lutein - (prescribed by other provider; otc) - 226 mg-200 unit- mg-0.8 mg-34.8 mg capsule - 1 (one) capsule(s) by mouth twice a day minocylcine 100mg acyclovir 400mg hdroxyzine 10mg q6 prn hydrocortisone cream prn ketoconazole cream prn prednisone 10mg daily discharge medications: 1. prednisone 10 mg tablet sig: one (1) tablet po daily (daily). 2. keppra 1,000 mg tablet sig: one (1) tablet po twice a day. 3. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 4. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 5. amiodarone 200 mg tablet sig: one (1) tablet po twice a day: take 200mg for one week, then decrease to 200mg daily ongoing. 6. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 7. heparin (porcine) 5,000 unit/ml solution sig: one (1) ml injection tid (3 times a day). 8. levothyroxine 100 mcg tablet sig: one (1) tablet po daily (daily). 9. quetiapine 25 mg tablet sig: one (1) tablet po bid (2 times a day). 10. timolol maleate 0.5 % drops sig: one (1) drop ophthalmic daily (daily). 11. latanoprost 0.005 % drops sig: one (1) drop ophthalmic hs (at bedtime). 12. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain/fever. 13. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 14. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). 15. therapeutic multivitamin liquid sig: five (5) ml po daily (daily). 16. novolog 100 unit/ml solution sig: sliding scale units subcutaneous four times a day: insulin sc sliding scale breakfast lunch dinner bedtime novalog novalog novalog novalog glucose insulin dose insulin dose insulin dose insulin dose mg/dl units units units units mg/dl units units units units mg/dl units units units units mg/dl units units units units mg/dl units units units units . 17. nystatin 100,000 unit/ml suspension sig: three (3) ml po three times a day for 5 days: thrush. discharge disposition: extended care facility: discharge diagnosis: thoracoabdominal aortic aneurysm s/p repair and s/p re-explor. for bleeding postop embolic cva postop seizure hypertension glaucoma vaginal prolapse stress incontinence gastroesophageal reflux disease hypothyroidism eczema bullous pemphigoid (currently on prednisone) discharge condition: alert and oriented x3 nonfocal max assist, lift to chair, weak lower extremities 2/5 strength incisional pain managed with oral analgesics incisions: thoracoabdominal incision - healing well, no erythema or drainage former chest tube site draining serosanguinous fluid requiring frequent dressing changes to keep the site dry. site is macerated but without sign of infection. edema 1+ lower extremity 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 6 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. at 2:45pm on cardiology: dr. at 3:15p vascular: dr. at 1:00p please call to schedule appointments with your primary care dr. ( in weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Extracorporeal circulation auxiliary to open heart surgery Diagnostic ultrasound of heart Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Reopening of recent thoracotomy site Resection of vessel with replacement, thoracic vessels Closed [endoscopic] biopsy of bronchus Diagnoses: Thrombocytopenia, unspecified Esophageal reflux Unspecified essential hypertension Long-term (current) use of steroids Unspecified acquired hypothyroidism Other convulsions Unspecified glaucoma Paroxysmal ventricular tachycardia Hemorrhage complicating a procedure Iatrogenic pneumothorax Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Hyperosmolality and/or hypernatremia Cerebral artery occlusion, unspecified with cerebral infarction Paraplegia Leukocytosis, unspecified Thoracoabdominal aneurysm, without mention of rupture Acute respiratory failure following trauma and surgery Other diseases of vocal cords Pemphigoid Other specified forms of effusion, except tuberculous Dysphonia