DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
FINAL DIAGNOSES:
1. Paroxysmal atrial fibrillation.
2. Coronary artery disease.
3. Hypothyroidism.
4. Status post coronary bypass graft surgery.
5. Status post aortic valve replacement.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old African-American female with a history of coronary artery disease and aortic stenosis, who underwent coronary bypass graft surgery and aortic valve replacement and was stable until last week. The patient had an episode of palpitations that lasted about half an hour, that subsided, and then three days later, she had another episode on the day of admission, again lasted about 20 minutes to half an hour with some trembling and palpitations.
She underwent transtelephonic monitor from the office, which revealed atrial fibrillation. By the time she came to the emergency room, she was in sinus rhythm. Because of the episodes of paroxysmal atrial fibrillation, she was admitted to the hospital for anticoagulation with heparin and Coumadin.
PAST MEDICAL HISTORY: Coronary artery disease, status post coronary bypass graft surgery and aortic valve replacement with history of mitral regurgitation, hypothyroidism, and hypertension.
MEDICATIONS: Synthroid 0.125 mg daily, amiodarone 200 mg daily, aspirin 81 mg daily, Plavix 75 mg daily, Lasix 40 mg daily, K-Dur 10 mEq daily, Toprol 25 mg daily, Hyzaar 50/12.5 mg daily, and Fosamax weekly.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: Smoker, quit 30 years ago.
PHYSICAL EXAMINATION: GENERAL: She was alert and oriented. VITAL SIGNS: Blood pressure 90/46 and pulse 80. NECK: No distention or carotid bruits. LUNGS: Clear breath sounds. HEART: Irregular rhythm, S1 and S2. There were clear valvular sounds with grade 2/6 systolic murmur. ABDOMEN: Soft, nondistended, and nontender. No masses or organomegaly. EXTREMITIES: Trace edema of the right leg.
EKG shows AV pacing. Chest x-ray shows no active disease.
LABORATORY DATA: Laboratory testing revealed BUN of 22 and creatinine of 1.3. Electrolytes were unremarkable. Potassium was 3.6 and hemoglobin was 13.8. Thyroid functions revealed TSH of 4.48.
HOSPITAL COURSE: The patient was admitted to the hospital and she was monitored. She remained in sinus rhythm. The amiodarone was increased to 200 mg b.i.d., and she was put on heparin drip as per protocol and started anticoagulation with Coumadin. She had no further episodes of atrial fibrillation during the hospitalization, and she remained in AV pacing. She had no symptoms and she reached a good level of anticoagulation with Coumadin; therefore, she is being discharged.
DISCHARGE MEDICATIONS: Synthroid 0.125 mg daily. Amiodarone will be increased to 200 mg b.i.d. on Monday, Wednesday, and Friday; on the other days, she will be on 200 mg daily. Furosemide 20 mg daily, potassium 10 mEq daily, metoprolol 25 mg daily, Hyzaar 50/12.5 mg daily, and Coumadin 2.5 mg alternating with 5 mg every other day. She will discontinue Plavix and aspirin.
DISCHARGE INSTRUCTIONS: She will have her followup PT/INR on Thursday in the office. She will continue to follow 4-gram sodium, low-fat, low-cholesterol diet. She may resume her previous exercise program at the cardiac rehab facility. The patient was alert and oriented at the time of discharge.
