DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Bivalvular heart disease.
BRIEF HISTORY: The patient is a (XX)-year-old gentleman who had a significant aortic stenosis as well as mitral regurgitation and coronary artery disease. In view of multivalvular problems and coronary artery disease, Dr. John Doe recommended proceeding with surgical replacement of his aortic valve with concomitant mitral valve repair as well as surgical myocardial revascularization. For this reason, he was admitted.
PAST MEDICAL HISTORY:
1. Valvular heart disease.
a. Mitral regurgitation.
b. Aortic insufficiency.
2. Coronary artery disease.
3. Dilated ascending aorta, 4.3 cm.
4. History of prostate cancer with radiation seed implantation approximately 12 years ago.
5. Peptic ulcer disease.
6. Partial gastrectomy secondary to a benign tumor.
7. History of nephrolithiasis.
HOSPITAL COURSE: Following admission, the patient underwent a presurgical and preanesthetic evaluation for valvular heart disease. He was taken to the operating room one month ago. At that time, a coronary artery bypass graft operation x1 was performed. The left internal mammary artery was utilized to bypass the left anterior descending artery. The aortic valve was replaced with a #23 mm supraannular pericardial valve. Dr. John Doe did not feel that his mitral valve was a repairable valve as this was a type II P1 valve, but it was heavily calcified posteriorly, and thus the valve was replaced with a #33 mm porcine valve. The left atrial appendage was also ligated.
Postoperatively, he was taken to the CVICU in stable condition and no inotropic support. By the first postoperative morning, he was weaned from mechanical ventilation and extubated without any difficulty. He did require a short postoperative course of atrial pacing secondary to a junctional rhythm, but this did resolve.
At about the second postoperative day, we were able to remove his pacing wires and chest tubes. Unfortunately, during the postoperative course, he did have a thrombocytopenia and was found to be positive for a heparin antibody. Argatroban was initiated following hematology consultation. The patient also had some altered mental status. This was thought to be secondary to sedation as once this was held, he seemed to improve.
On about the postoperative day #4, he developed a hypotensive episode, which responded immediately to fluid. We did obtain an echocardiogram, and both aortic and mitral valve bioprostheses were functioning appropriately. There was no evidence of any cardiac tamponade. After a slightly prolonged hospitalization, secondary to the requirement of being appropriately anticoagulated as well as requiring aggressive physical therapy and pulmonary care, he was eventually discharged.
DISCHARGE CONDITION: Good.
DISCHARGE INSTRUCTIONS: The patient was appropriately instructed regarding wound care. He is not to lift any heavy objects of over 5 pounds or drive a car for the next month, to resume an American Heart Association Diet. The patient is to see Dr. Jane Doe in 2 weeks. Dr. John Doe will follow him up in 2 weeks as well. He will take amoxicillin, Plendil, and Coumadin. The patient is to call our office regarding increased chest pain, shortness of breath, fevers.
PROCEDURE PERFORMED: Mitral valve replacement, aortic valve replacement, and coronary artery bypass graft operation x1.
COMPLICATIONS: Postoperative heparin-induced thrombocytopenia.
