Resident A - Chart

Resident Chart Section

Date of Birth: 8/6/32
Sex: F

Admission 

Discharge 

IDENTIFICATION

Patient is a 62-year-old female with a past medical history of inferior wall myocardial infarction in 2010 transferred from Sturdy Hospital for percutaneous transluminal coronary angioplasty for acute therapy of documented inferoposterior myocardial infarction.

HISTORY OF PRESENT ILLNESS

The patient has a past medical history significant for coronary artery disease, hypertension, hypercholesterolemia, status post percutaneous transluminal coronary angioplasty of right coronary artery seven years after suffering an inferior wall myocardial infarction. At the time of that admission the patient presented with acute onset of shortness of breath and arm heaviness. A cardiac catheterization done at that time revealed lesions of the OM1 and a non-critical stenosis of the left anterior descending coronary artery in addition to the high grade right coronary artery lesion which was angioplastied at that time. The ejection fraction was estimated to be 41%. Since that angioplasty, the patient had been managed medically with Cardizem, Toprol, and diuretics. The patient remained asymptomatic until the day of admission when the patient noted sudden onset of dyspnea upon arising from bed which was accompanied with bilateral arm heaviness. The patient rested for a few minutes of her pain and began to develop lightheadedness. The patient denied any nausea, diaphoresis, palpitations or chest pain. The patient presented at the Sturdy Hospital 1 1/2 hours after the onset of symptoms. In the Sturdy Hospital Emergency Room, the patient was noted to be in acute respiratory distress with marked pulmonary edema by physical examination and by chest X-ray. The patient was intubated for treatment of respiratory failure. The patient vomited after having a nasogastric tube placed and having just received 80 mEq of potassium chloride via the nasogastric tube. There was a question of aspiration according to the Sturdy Emergency Room physician. The electrocardiogram done in that Emergency Room was consistent with inferior wall myocardial infarction and positive ST elevation in lead V4 on the right sided electrocardiogram. The patient went on to develop ventricular fibrillation arrest in the Sturdy Emergency Room. She was shocked with 300 joules which lead to first a normal sinus rhythm which was then followed by asystole. epinephrine and Atropine were administered intravenously, and patient returned to ventricular fibrillation rhythm. Again, the patient was shocked, this time at 360 joules and the patient returned to normal sinus rhythm with complete heart block. The patient was placed on Lidocaine and transferred to the Beth Israel Hospital.

PAST MEDICAL HISTORY

1. Coronary artery disease
2. Status post total abdominal hysterectomy
3. Status post cholecystectomy
4. Hypercholesterolemia
5. Hypertension
6. No history of diabetes mellitus
7. Obesity

MEDICATIONS ON ADMISSION

1. Mevacor 20 mg po b.i.d.
2. Diltiazem-CD 180 mg. q. day
3. Toprol-XL 100 mg. po q. day
4. Dyazide

ALLERGIES

NO KNOWN DRUG ALLERGIES

FAMILY HISTORY

Patient's brother died of a myocardial infarction at age 64. Father died of a myocardial infarction at age 50. Mother died of cancer. 

SOCIAL HISTORY

The patient works on an assembly line making rings. She lives with the younger of her two sons. The patient denies consumption of alcohol. The patient has a positive smoking history of one pack per day x 30 years which was stopped nine years ago. 

PHYSICAL EXAMINATION

In general the patient was a lethargic obese white female as stated on admission. Vital signs included a pulse of 74, blood pressure 120/65, respiratory rate 14, and the patient was afebrile. Head, eyes, ears, nose and throat exam revealed pupil equal and reactive to light, anicteric sclerae and no oropharyngeal lesions. Neck exam revealed 2+ symmetric carotid pulses, no bruits, and no ostensible jugular venous distension. Lungs were clear to auscultation anteriorly. There were moderate inspiratory crackles at the right base, without wheezes. Cardiac exam revealed a regular rate and rhythm, with very distant S1 and S2 and no appreciable murmur. Abdominal exam revealed hypoactive bowel sounds with a soft, nontender, nondistended abdomen without organomegaly. There was a femoral arterial line and a pulmonary artery line in place in the right groin and the dressing was clean and dry and intact. Extremities revealed no clubbing, cyanosis or edema. The pulses were equal and symmetric, 2+/2+. 

LABORATORY

Labs. were as follows; white blood cell count 20, hematocrit 40.2, platelets 377. Differential included 92 neutrophils, 1 band, 6 lymphocytes and one mono. Sodium 140, potassium 4.1, BUN 12, creatinine 1.1, glucose 233, calcium 8.2, magnesium 2.2, phosphorus 8.2, CPK 371. Urinalysis at the time revealed on bacteria but was positive for protein and glucose. There were also white blood cells in the urine estimated to be 23 per high powered field. Sputum culture was obtained from a tracheal aspirate and revealed greater than 25 past medical history per high powered field, Gram positive cocci in pairs. Electrocardiogram revealed normal sinus rhythm at 83 beats per minute, with an axis of 0. There is a left atrial abnormality. There are Q waves in leads 3 and AVF. There were T wave inversions in leads 3 and AVF with flattened T waves in 2, V5 and V6. Chest X-ray revealed a left effusion, prominent pulmonary vasculature and increasing opacity at the right lower lung field which is felt to be more likely a soft tissue phenomenon. 

HOSPITAL COURSE

Upon admission to the Beth Israel Hospital, the patient was continued on intravenous nitroglycerin, heparin, aspirin and Lopressor. The patient was weaned of the Lidocaine drip. There had been no notable ectopy during her stay in the Cardiac Care Unit. The patient had arrived intubated but was oxygenating and ventilating well and consequently was extubated without difficulty. The patient had several ongoing issues.

1. Cardiovascular. The patient received a cardiac catheterization on 7/20/95 which revealed diffuse disease in the left anterior descending coronary artery (80% stenosis in the mid-region, 60% stenosis in the proximal region). There was a 60% lesion in the proximal left circumflex, 80% stenosis in the right coronary artery which was stented to a residual of 0% stenosis. A 70% lesion in the right coronary artery mid-region was also stented to a residual of 0% stenosis. The patient remained without chest pain after the procedure and was subsequently weaned off her intravenous nitroglycerin and heparin. The patient remained on coumadin with a therapeutic INR of between 3 and 4. The patient tolerated her cardiac rehabilitation well, without complaints of chest pain during ambulation or the stair exercises. Echocardiogram was done on 7/25/95 which revealed a reduced ejection fraction estimated to be 25-30%/ The right ventricular free wall was hypokinetic. There was moderate mitral regurgitation, a dilated left ventricle, global hypokinesis, inferior akinesis, distant inferior wall dyskinesis, and fast motion in the distal anterior, apical and lateral walls. The patient then underwent a submaximal exercise stress test on 7/27/95 which revealed the following. There was a moderate fixed inferior wall, moderate partially reversible anterior wall, severe partially reversible apical wall defects with moderate left ventricular enlargement. Since the patient had been pain free since her transfer to the Cardiology Stepdown unit the patient agreed with the house team that medical management optimization would be the plan for now. The patient would follow up with a maximal exercise stress test in six weeks. The patient would continue with cardiac rehabilitation as an outpatient. The patient was informed that should new symptoms occur that she should notify her doctor for possible re- evaluation of her coronary anatomy and discussion of further interventions, including revascularization via surgery or further angioplasty.

2. Pulmonary. The patient had arrived to the Cardiac Care Unit intubated but subsequently oxygenated and ventilated well and was extubated. The patient maintained good oxygen saturations first on 2 liters nasal cannula and was then subsequently weaned off all oxygen. Although the patient had occasional cough there was no evidence of pneumonia, effusion or pulmonary congestion prior to discharge. The patient had two episodes of hemoptysis of a quarter sized blood clot while on heparin therapy. This was accompanied with normal hematocrit and without any symptoms. This had resolved by the time of discharge. 

3. Infectious disease. The patient on admission had an elevated white blood cell count of 20,000. The right based increased density on chest X-ray upon admission was first felt to be a possible aspiration pneumonia. The initial sputum revealed Gram positive cocci. On subsequent X-rays this increased density was felt to possibly be more to do with subcutaneous density than an aspiration. Patient was not treated with antibiotics for this and her white blood cell count subsequently resolved to normal range and patient did not have temperature spikes. The patient did appear to have a urinary tract infection during the admission with a urinalysis on 7/20 revealing 22 white blood cells, 5 red blood cells in the setting of an elevated white blood cell count. The urine culture grew E.coli greater than 100,000 colonies which was resistant to ampicillin. The patient was given one day of intravenous gentamicin therapy and three days of Bactrim po therapy. The patient remained afebrile and denied any symptoms of dysuria, increased urinary frequency or hematuria. 

4. Renal. The patient on admission had proteinuria and glycosuria although she had no history of diabetes mellitus. The patient was given regular insulin by sliding scale as needed. Her subsequent glucoses had decreased and appeared to remain within normal limits with a peak of 233, the remaining glucoses remaining in the mid to low 100s. A glucosamine was obtained on 7/22 and was estimated to be 197. Glycosylated hemoglobin A1C was 6.7. Thus it was felt that the patient was not diabetic. 

CONDITION ON DISCHARGE

The patient was ambulatory, without chest pain, off all intravenous medications and taking adequate amounts of po. The Patient was off oxygen.

DISCHARGE MEDICATIONS

1. coumadin 4 mg. po on each of the three days after discharge. Afterwards the patient will return to have her PT and INR checked.
2. One aspirin a day
3. Isordil 10 mg. po t.i.d.
4. Norvasc 2.5 mg. po q. day
5. Mevacor 20 mg. po q. day
6. Lisinopril 20 mg. po q. day
7. Ticlid 250 mg. po b.i.d.

The Ticlid, coumadin and Norvasc were to be continued for one month as per the stent protocol. At that time the Ticlid and coumadin will be discontinued. At that time the primary care physician will decided whether Norvasc should be continued. 

DISCHARGE STATUS

Rehab facility 

PATIENT INSTRUCTIONS

The patient will take coumadin as noted above. The patient will follow up with Dr. ******* on Monday to haver PT and INR evaluated. The patient will return to Beth Israel Hospital for a exercise stress test in six weeks and for follow up with Dr. *******. If the patient develops worsening symptoms the patient is to notify her doctor and be evaluated.

DISCHARGE DIAGNOSIS

1. Inferoposterior myocardial infarction status post angioplasty with two stents in the right coronary artery.
2. Status post inferior wall myocardial infarction in 1988
3. Coronary artery disease
4. Hypercholesterolemia
5. Hypertension

Patient Name: [Patient Name] Age: 62 years Gender: Female Medical Diagnosis: Acute Respiratory Distress Syndrome secondary to Inferior Wall Myocardial Infarction

History: The patient is a 62-year-old female with a significant past medical history of Coronary artery disease, status post total abdominal hysterectomy, status post cholecystectomy, hypercholesterolemia, hypertension, and obesity. The patient was admitted to the hospital with acute onset of shortness of breath and arm heaviness, which was found to be secondary to Inferior Wall Myocardial Infarction. She was intubated for treatment of respiratory failure and underwent multiple defibrillations due to ventricular fibrillation arrest.

Physical Therapy Assessment: The patient is currently deconditioned and requires physical therapy to improve her strength, endurance, balance, and functional mobility. The patient's vital signs are stable, and she is currently receiving oxygen therapy via a nasal cannula.

Range of Motion: The patient presents with limited range of motion in the upper and lower extremities. Active range of motion in the shoulder, elbow, wrist, hip, knee, and ankle joints is limited and painful. Passive range of motion is within normal limits.

Strength: The patient presents with significant muscle weakness in all extremities, particularly in the upper extremities. Grip strength is weak, and the patient has difficulty performing activities of daily living.

Endurance: The patient presents with decreased endurance and easily fatigues with minimal activity. She is able to tolerate a short distance of walking with moderate assistance.

Balance: The patient presents with impaired balance and requires assistance to maintain a seated position. She is unable to stand or walk without assistance.

Functional Mobility: The patient is currently bedbound and requires assistance with all activities of daily living, including feeding, toileting, and bathing.

Plan of Care: The physical therapy plan of care will focus on improving the patient's strength, endurance, balance, and functional mobility. This will be accomplished through the use of therapeutic exercises, gait training, and balance activities. The patient will also receive education on energy conservation techniques and fall prevention strategies.

Physical Therapy Treatment: The patient will participate in active range of motion exercises, strengthening exercises, and endurance training. The patient will also receive gait training and balance activities, as well as education on energy conservation techniques and fall prevention strategies.

Patient Goals:

  1. Improve upper and lower extremity strength and endurance.
  2. Increase functional mobility and independence in activities of daily living.
  3. Improve balance and reduce fall risk.

Follow-Up: The patient will receive physical therapy treatment three times a week, and progress will be monitored closely. The physical therapy plan of care will be re-evaluated as necessary to ensure the patient is making progress towards achieving her goals.

Patient Information: Name: Jane Doe Age: 62 Gender: Female Date of admission: [insert date] Primary diagnosis: Deconditioning PMH:

  • Coronary artery disease
  • Total abdominal hysterectomy
  • Cholecystectomy
  • Hypercholesterolemia
  • Hypertension
  • No history of diabetes mellitus
  • Obesity

Medical History and Current Condition: Jane Doe was admitted to the hospital due to acute respiratory distress and pulmonary edema. She was intubated for treatment of respiratory failure and was diagnosed with inferior wall myocardial infarction. She experienced ventricular fibrillation arrest and was shocked twice to restore normal sinus rhythm with complete heart block. She was then transferred to Beth Israel Hospital.

Occupational Therapy Evaluation: Occupational therapy evaluation was conducted to assess Jane Doe's current level of functioning and determine appropriate interventions to address her deconditioning.

Areas assessed:

  1. Activities of daily living (ADLs): Jane Doe was able to perform some basic ADLs with moderate assistance but required complete assistance with bathing and grooming tasks.
  2. Functional mobility: Jane Doe was unable to stand without assistance due to generalized weakness and fatigue.
  3. Cognition: Jane Doe demonstrated intact cognitive abilities with no signs of confusion or disorientation.
  4. Psychosocial status: Jane Doe reported feeling anxious and frustrated about her current condition and expressed concern about her ability to return to her previous level of functioning.

Assessment results: Based on the evaluation, Jane Doe demonstrated deficits in ADLs and functional mobility due to deconditioning. She required moderate to complete assistance with ADLs and was unable to stand without assistance. She demonstrated intact cognitive abilities and expressed feelings of anxiety and frustration about her current condition.

Occupational Therapy Plan of Care: The following interventions were recommended to address Jane Doe's deficits:

  1. ADL retraining and practice with graded activities to promote independence
  2. Bed mobility and transfer training to improve functional mobility
  3. Energy conservation techniques to address fatigue and increase endurance
  4. Anxiety management techniques to address psychosocial concerns and improve overall well-being

The occupational therapy team will collaborate with other healthcare professionals to ensure the best possible outcomes for Jane Doe.

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DM

HTN

COPD

High Fracture

Hyperlipidemia

GERD

CKD

Trach

OSA

Flu 2011

Flu 2012

Flu 2013

Flu 2015

PNA PCV 13

PNA PCV 23

White Male, catholic, education Master Level, 

Date of birth (DOB) 02/01/1921

Emergency Contact

Mary Doe 781-244-7652- sister

Medicare 123569831A

Mass health- community – 100003901234

Facility MD following-Dr James Kamwana

Preferred Hospital- Regional medical center 

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  1. Complete Blood Count (CBC)

    • White blood cell count: 14.6 x 10^9/L (high)
    • Hemoglobin: 11.3 g/dL (low)
    • Hematocrit: 33.5% (low)
    • Platelet count: 215 x 10^9/L (within normal limits)

  2. Comprehensive Metabolic Panel (CMP)

    • Sodium: 141 mmol/L (within normal limits)
    • Potassium: 3.2 mmol/L (low)
    • Chloride: 105 mmol/L (within normal limits)
    • Carbon dioxide: 22 mmol/L (low)
    • Blood urea nitrogen (BUN): 36 mg/dL (high)
    • Creatinine: 1.2 mg/dL (within normal limits)
    • Glucose: 128 mg/dL (high)
    • Calcium: 8.4 mg/dL (within normal limits)
    • Total protein: 6.2 g/dL (within normal limits)
    • Albumin: 3.5 g/dL (within normal limits)
    • Alkaline phosphatase: 74 U/L (within normal limits)
    • Alanine aminotransferase (ALT): 48 U/L (high)
    • Aspartate aminotransferase (AST): 82 U/L (high)

  3. Cardiac biomarkers

    • Troponin I: 3.6 ng/mL (high)
    • CK-MB: 50 U/L (high)

  4. Arterial Blood Gas (ABG)

    • pH: 7.28 (low)
    • PaO2: 59 mmHg (low)
    • PaCO2: 56 mmHg (high)
    • HCO3: 25 mmol/L (within normal limits)
    • SaO2: 88% (low)

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