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Consult for subcutaneous emphysema and a small right-sided pneumothorax secondary to trauma.

Cardiovascular / Pulmonary

Pneumothorax & Subcutaneous Emphysema

REASON FOR CONSULTATION:, Pneumothorax and subcutaneous emphysema.,HISTORY OF PRESENT ILLNESS: , The patient is a 48-year-old male who was initially seen in the emergency room on Monday with complaints of scapular pain. The patient presented the following day with subcutaneous emphysema and continued complaints of pain as well as change in his voice. The patient was evaluated with a CT scan of the chest and neck which demonstrated significant subcutaneous emphysema, a small right-sided pneumothorax, but no other findings. The patient was admitted for observation.,PAST SURGICAL HISTORY: , Hernia repair and tonsillectomy.,ALLERGIES: , Penicillin.,MEDICATIONS: , Please see chart.,REVIEW OF SYSTEMS:, Not contributory.,PHYSICAL EXAMINATION:,GENERAL: Well developed, well nourished, lying on hospital bed in minimal distress.,HEENT: Normocephalic and atraumatic. Pupils are equal, round, and reactive to light. Extraocular muscles are intact.,NECK: Supple. Trachea is midline.,CHEST: Clear to auscultation bilaterally.,CARDIOVASCULAR: Regular rate and rhythm.,ABDOMEN: Soft, nontender, and nondistended. Normoactive bowel sounds.,EXTREMITIES: No clubbing, edema, or cyanosis.,SKIN: The patient has significant subcutaneous emphysema of the upper chest and anterior neck area although he states that the subcutaneous emphysema has improved significantly since yesterday.,DIAGNOSTIC STUDIES:, As above.,IMPRESSION: , The patient is a 48-year-old male with subcutaneous emphysema and a small right-sided pneumothorax secondary to trauma. These are likely a result of either a parenchymal lung tear versus a small tracheobronchial tree rend.,RECOMMENDATIONS:, At this time, the CT Surgery service has been consulted and has left recommendations. The patient also is awaiting bronchoscopy per the Pulmonary Service. At this time, there are no General Surgery issues.

cardiovascular / pulmonary, trauma, tracheobronchial, bronchoscopy, scapular pain, subcutaneous emphysema, pneumothorax, subcutaneous, emphysema,

Cardiology consultation regarding preoperative evaluation for right hip surgery. Patient with a history of coronary artery disease status post bypass surgery

Cardiovascular / Pulmonary

Preop Cardiac Consult

HISTORY OF PRESENT ILLNESS: , I was kindly asked to see Ms. ABC by Dr. X for cardiology consultation regarding preoperative evaluation for right hip surgery. She is a patient with a history of coronary artery disease status post bypass surgery in 1971 who tripped over her oxygen last p.m. she states and fell. She suffered a right hip fracture and is being considered for right hip replacement. The patient denies any recent angina, but has noted more prominent shortness of breath.,Past cardiac history is significant for coronary artery disease status post bypass surgery, she states in 1971, I believe it was single vessel. She has had stress test done in our office on September 10, 2008, which shows evidence of a small apical infarct, no area of ischemia, and compared to study of December of 2005, there is no significant change. She had a transthoracic echocardiogram done in our office on August 29, 2008, which showed normal left ventricular size and systolic function, dilated right ventricle with septal flattening of the left ventricle consistent with right ventricular pressure overload, left atrial enlargement, severe tricuspid regurgitation with estimated PA systolic pressure between 75-80 mmHg consistent with severe pulmonary hypertension, structurally normal aortic and mitral valve. She also has had some presumed atrial arrhythmias that have not been sustained. She follows with Dr. Y my partner at Cardiology Associates.,PAST MEDICAL HISTORY: ,Other medical history includes severe COPD and she is oxygen dependent, severe pulmonary hypertension, diabetes, abdominal aortic aneurysm, hypertension, dyslipidemia. Last ultrasound of her abdominal aorta done June 12, 2009 states that it was fusiform, infrarenal shaped aneurysm of the distal abdominal aorta measuring 3.4 cm unchanged from prior study on June 11, 2008.,MEDICATIONS:, As an outpatient:,1. Lanoxin 0.125 mg, 1/2 tablet once a day.,2. Tramadol 50 mg p.o. q.i.d. as needed.,3. Verapamil 240 mg once a day.,4. Bumex 2 mg once a day.,5. ProAir HFA.,6. Atrovent nebs b.i.d.,7. Pulmicort nebs b.i.d.,8. Nasacort 55 mcg, 2 sprays daily.,9. Quinine sulfate 325 mg p.o. q.h.s. p.r.n.,10. Meclizine 12.5 mg p.o. t.i.d. p.r.n.,11. Aldactone 25 mg p.o. daily.,12. Theo-24 200 mg p.o., 2 in the morning.,13. Zocor 40 mg once a day.,14. Vitamin D 400 units twice daily.,15. Levoxyl 125 mcg once a day.,16. Trazodone 50 mg p.o. q.h.s. p.r.n.,17. Janumet 50/500, 1 tablet p.o. b.i.d.,ALLERGIES: , To medications are listed as:,1. LEVAQUIN.,2. AZITHROMYCIN.,3. ADHESIVE TAPE.,4. BETA BLOCKERS. When I talked to the patient about the BETA BLOCKER, she states that they made her more short of breath in the past.,She denies shrimp, seafood or dye allergy.,FAMILY HISTORY: ,Significant for heart problems she states in her mother and father.,SOCIAL HISTORY: ,She used to smoke cigarettes and smoked from the age of 14 to 43 and quit at the time of her bypass surgery. She does not drink alcohol nor use illicit drugs. She lives alone and is widowed. She is a retired custodian at University. Of note, she is accompanied with her verbal consent by her daughter and grandson at the bedside.,REVIEW OF SYSTEMS: ,Unable to obtain as the patient is somnolent from her pain medication, but she is alert and able to answer my direct questions.,PHYSICAL EXAM: , Height 5'2", weight 160 pounds, temperature is 99.5 degrees ranging up to 101.6, blood pressure 137/67 to 142/75, pulse 92, respiratory rate 16, O2 saturation 93-89%. On general exam, she is an elderly, chronically ill appearing woman in no acute distress. She is able to lie flat, she does have pain if she moves. HEENT shows the cranium is normocephalic, atraumatic. She has dry mucosal membranes. Neck veins are not distended. There are no carotid bruits. Visible skin is warm and she appears pale. Affect appropriate and she is somnolent from her pain medications, but arouses easily and answers my direct questions appropriately. Lungs are clear to auscultation anteriorly, no wheezes. Cardiac exam S1, S2 regular rate, soft holosystolic murmur heard over the tricuspid region. No rub nor gallop. PMI is nondisplaced, unable to appreciate RV heave. Abdomen soft, mildly distended, appears benign. Extremities with trivial peripheral edema. Pulses grossly intact. She has quite a bit of pain at the right hip fracture.,DIAGNOSTIC/LABORATORY DATA: ,Sodium 135, potassium 4.7, chloride 99, bicarbonate 33, BUN 22, creatinine 1.3, glucose 149, troponin was 0.01 followed by 0.04. Theophylline level 16.6 on January 23, 2009. TSH 0.86 on March 10, 2009. INR 1.06. White blood cell count 9.5, hematocrit 35, platelet count 160.,EKG done July 16, 2009 at 7:31:15, shows sinus rhythm, which showed PR interval of about 118 milliseconds, nonspecific T wave changes. When compared to EKG done July 15, 2009 at 1948, previously there more frequent PVCs seen. This ECG appears similar to the ones she has had done previously in our office including on June 11, 2009, although the T wave changes are a bit more prominent, which is a nonspecific finding.,IMPRESSION: , She is an 81-year-old woman with severe O2 requiring chronic obstructive pulmonary disease with evidence of right heart overload, as well as known coronary artery disease status post single-valve bypass in 1971 suffering a right hip fracture for whom a right hip replacement is being considered. I have had a long discussion with the patient, as well as her daughter and grandson at the bedside today. There are no clear absolute cardiac contraindications that I can see. Of note at the time of this dictation a chest x-ray report is pending. With that being said, however, she is extremely high risk more from a pulmonary than cardiac standpoint. We did also however review that untreated hip fractures themselves have very high morbidity and mortality incidences. The patient is deciding on surgery and is clearly aware that she is very high risk for proposed surgery, as well as if she were to not pursue surgery.,PLAN/RECOMMENDATIONS:,1. The patient is going to decide on surgery. If she does have the right hip surgery, I would recommend overnight observation in the intensive care unit.,2. Optimize pulmonary function and pursue aggressive DVT prophylaxis.,3. Continue digoxin and verapamil. Again, the patient describes clear INTOLERANCE TO BETA BLOCKERS by her history.

Left hemothorax, rule out empyema. Insertion of a 12-French pigtail catheter in the left pleural space.

Cardiovascular / Pulmonary

Pigtail Catheter Insertion

PREOPERATIVE DIAGNOSIS: ,Left hemothorax, rule out empyema.,POSTOPERATIVE DIAGNOSIS: , Left hemothorax rule out empyema.,PROCEDURE: , Insertion of a 12-French pigtail catheter in the left pleural space.,PROCEDURE DETAIL: ,After obtaining informed consent, the patient was taken to the minor OR in the Same Day Surgery where his posterior left chest was prepped and draped in a usual fashion. Xylocaine 1% was injected and then a 12-French pigtail catheter was inserted in the medial scapular line about the eighth intercostal space. It was difficult to draw fluid by syringe, but we connected the system to a plastic bag and by gravity started draining at least 400 mL while we were in the minor OR. Samples were sent for culture and sensitivity, aerobic and anaerobic.,The patient and I decided to admit him for a period of observation at least overnight.,He tolerated the procedure well and the postprocedure chest x-ray showed no complications.

cardiovascular / pulmonary, chest, pleural space, pigtail catheter, insertion, empyema, hemothorax,

Chest tube talc pleurodesis of the right chest.

Cardiovascular / Pulmonary

Pleurodesis

PREOPERATIVE DIAGNOSIS:, Large recurrent right pleural effusion.,POSTOPERATIVE DIAGNOSIS:, Large recurrent right pleural effusion.,PROCEDURE:,1. Conscious sedation.,2. Chest tube talc pleurodesis of the right chest.,INDICATIONS: , The patient is a 65-year-old lady with a history of cirrhosis who has developed a recurrent large right pleural effusion. Chest catheter had been placed previously, and she had been draining up to 1.5 liters of serous fluid a day. Eventually, this has decreased and a talc pleurodesis is being done to see her pleural effusion does not recur.,SPECIMENS:, None.,ESTIMATED BLOOD LOSS: , Zero.,NARRATIVE:, After obtaining informed consent from the patient and her daughter, the patient was assessed and found to be in good condition and a good candidate for conscious sedation. Vital signs were taken. These were stable, so the patient was then given initially 0.5 mg of Versed and 2 mg of morphine IV. After a couple of minutes, she was assessed and found to be awake but calm, so then the chest tube was clamped and then through the chest tube a solution of 120 mL of normal saline containing 5 g of talc and 40 mg of lidocaine were then put into her right chest taking care that no air would go in to create a pneumothorax. She was then laid on her left lateral decubitus position for 5 minutes and then turned into the right lateral decubitus position for 5 minutes and then the chest tube was unclamped. The patient was given additional 0.5 mg of Versed and 0.5 mg of Dilaudid IV achieving a state where the patient was comfortable but readily responsive. The patient tolerated the procedure well. She did complain of up to a 7/10 pain, but quickly this was brought under control. The chest tube was unclamped. Now, the patient will be left to rest and she will get a chest x-ray in the morning.

cardiovascular / pulmonary, chest tube talc pleurodesis, lateral decubitus position, decubitus position, talc pleurodesis, pleural effusion, chest tube, chest, pleurodesis, talc, recurrent, pleural, effusion, tube

Ultrasound-guided right pleurocentesis for right pleural effusion with respiratory failure and dyspnea.

Cardiovascular / Pulmonary

Pleurocentesis

PREOPERATIVE DIAGNOSIS: , Right pleural effusion with respiratory failure and dyspnea.,POSTOPERATIVE DIAGNOSIS: , Right pleural effusion with respiratory failure and dyspnea.,PROCEDURE: , Ultrasound-guided right pleurocentesis.,ANESTHESIA: , Local with lidocaine.,TECHNIQUE IN DETAIL: , After informed consent was obtained from the patient and his mother, the chest was scanned with portable ultrasound. Findings revealed a normal right hemidiaphragm, a moderate right pleural effusion without septation or debris, and no gliding sign of the lung on the right. Using sterile technique and with ultrasound as a guide, a pleural catheter was inserted and serosanguinous fluid was withdrawn, a total of 1 L. The patient tolerated the procedure well. Portable x-ray is pending.

cardiovascular / pulmonary, pleural effusion, dyspnea, gliding sign, hemidiaphragm, pleural catheter, pleurocentesis, respiratory, serosanguinous fluid, ultrasound, pleural,

A middle-aged white female undergoing autologous stem cell transplant for multiple myeloma, now with paroxysmal atrial fibrillation.

Cardiovascular / Pulmonary

Paroxysmal Atrial Fibrillation

INDICATION: , Paroxysmal atrial fibrillation.,HISTORY OF PRESENT ILLNESS: ,The patient is a pleasant 55-year-old white female with multiple myeloma. She is status post chemotherapy and autologous stem cell transplant. Latter occurred on 02/05/2007. At that time, she was on telemetry monitor and noticed to be in normal sinus rhythm.,As part of study protocol for investigational drug for prophylaxis against mucositis, she had electrocardiogram performed on 02/06/2007. This demonstrated underlying rhythm of atrial fibrillation with rapid ventricular response at 125 beats per minute. She was subsequently transferred to telemetry for observation. Cardiology consultation was requested. Prior to formal consultation, the patient did have an echocardiogram performed on 02/06/2007, which showed a structurally normal heart with normal left ventricular (LV) systolic function, ejection fraction of 60%, aortic sclerosis without stenosis, a trivial pericardial effusion with no evidence for immunocompromise and mild tricuspid regurgitation with normal pulmonary atrial pressures. Overall, essentially normal heart.,At the time of my evaluation, the patient felt somewhat jittery and nervous, but otherwise asymptomatic.,PAST MEDICAL HISTORY:, Multiple myeloma, diagnosed in June of 2006, status post treatment with thalidomide and Coumadin. Subsequently, with high-dose chemotherapy followed by autologous stem cell transplant.,PAST SURGICAL HISTORY: , Cosmetic surgery of the nose and forehead.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,CURRENT MEDICATIONS,1. Acyclovir 400 mg p.o. b.i.d.,2. Filgrastim 300 mcg subcutaneous daily.,3. Fluconazole 200 mg daily.,4. Levofloxacin 250 mg p.o. daily.,5. Pantoprazole 40 mg daily.,6. Ursodiol 300 mg p.o. b.i.d.,7. Investigational drug is directed ondansetron 24 mg p.r.n.,FAMILY HISTORY: , Unremarkable. Father and mother both alive in their mid 70s. Father has an unspecified heart problem and diabetes. Mother has no significant medical problems. She has one sibling, a 53-year-old sister, who has a pacemaker implanted for unknown reasons.,SOCIAL HISTORY: , The patient is married. Has four adult children. Good health. She is a lifetime nonsmoker, social alcohol drinker.,REVIEW OF SYSTEMS: , Prior to treatment for her multiple myeloma, she was able to walk four miles nonstop. Currently, she has dyspnea on exertion on the order of one block. She denies any orthopnea or paroxysmal nocturnal dyspnea. She denies any lower extremity edema. She has no symptomatic palpitations or tachycardia. She has never had presyncope or syncope. She denies any chest pain whatsoever. She denies any history of coagulopathy or bleeding diathesis. Her oncologic disorder is multiple myeloma. Pulmonary review of systems is negative for recurrent pneumonias, bronchitis, reactive airway disease, exposure to asbestos or tuberculosis. Gastrointestinal (GI) review of systems is negative for known gastroesophageal reflux disease, GI bleed, and hepatobiliary disease. Genitourinary review of systems is negative for nephrolithiasis or hematuria. Musculoskeletal review of systems is negative for significant arthralgias or myalgias. Central nervous system (CNS) review of systems is negative for tic, tremor, transient ischemic attack (TIA), seizure, or stroke. Psychiatric review of systems is negative for known affective or cognitive disorders.,PHYSICAL EXAMINATION,GENERAL: This is a well-nourished, well-developed white female who appears her stated age and somewhat anxious.,VITAL SIGNS: She is afebrile at 97.4 degrees Fahrenheit with a heart rate ranging from 115 to 150 beats per minute, irregularly irregular. Respirations are 20 breaths per minute and blood pressure ranges from 90/59 to 107/68 mmHg. Oxygen saturation on room air is 94%.,HEENT: Benign being normocephalic and atraumatic. Extraocular motions are intact. Her sclerae are anicteric and conjunctivae are noninjected. Oral mucosa is pink and moist.,NECK: Jugular venous pulsations are normal. Carotid upstrokes are palpable bilaterally. There is no audible bruit. There is no lymphadenopathy or thyromegaly at the base of the neck.,CHEST: Cardiothoracic contour is normal. Lungs, clear to auscultation in all lung fields.,CARDIAC: Irregularly irregular rhythm and rate. S1, S2 without a significant murmur, rub, or gallop appreciated. Point of maximal impulse is normal, no right ventricular heave.,ABDOMEN: Soft with active bowel sounds. No organomegaly. No audible bruit. Nontender.,LOWER EXTREMITIES: Nonedematous. Femoral pulses were deferred.,LABORATORY DATA: , EKG, electrocardiogram showed underlying rhythm of atrial fibrillation with a rate of 125 beats per minute. Nonspecific ST-T wave abnormality is seen in the inferior leads only.,White blood cell count is 9.8, hematocrit of 30 and platelets 395. INR is 0.9. Sodium 136, potassium 4.2, BUN 43 with a creatinine of 2.0, and magnesium 2.9. AST and ALT 60 and 50. Lipase 343 and amylase 109. BNP 908. Troponin was less than 0.02.,IMPRESSION: , A middle-aged white female undergoing autologous stem cell transplant for multiple myeloma, now with paroxysmal atrial fibrillation.,Currently enrolled in a blinded study, where she may receive a drug for prophylaxis against mucositis, which has at least one reported incident of acceleration of preexisting tachycardia.,RECOMMENDATIONS,1. Atrial fibrillation. The patient is currently hemodynamically stable, tolerating her dysrhythmia. However, given the risk of thromboembolic complications, would like to convert to normal sinus rhythm if possible. Given that she was in normal sinus rhythm approximately 24 hours ago, this is relatively acute onset within the last 24 hours. We will initiate therapy with amiodarone 150 mg intravenous (IV) bolus followed by mg/minute at this juncture. If she does not have spontaneous cardioversion, we will consider either electrical cardioversion or anticoagulation with heparin within 24 hours from initiation of amiodarone.,As part of amiodarone protocol, please check TSH. Given her preexisting mild elevation of transaminases, we will follow LFTs closely, while on amiodarone.,2. Thromboembolic risk prophylaxis, as discussed above. No immediate indication for anticoagulation. If however she does not have spontaneous conversion within the next 24 hours, we will need to initiate therapy. This was discussed with Dr. X. Preference would be to run intravenous heparin with PTT of 45 during her thrombocytopenic nadir and initiation of full-dose anticoagulation once nadir is resolved.,3. Congestive heart failure. The patient is clinically euvolemic. Elevated BNP possibly secondary to infarct or renal insufficiency. Follow volume status closely. Follow serial BNPs.,4. Followup. The patient will be followed while in-house, recommendations made as clinically appropriate.

Coil embolization of patent ductus arteriosus.

Cardiovascular / Pulmonary

Patent Ductus Arteriosus

HISTORY: , The patient is a 5-1/2-year-old, who recently presented with a cardiac murmur diagnosed due to a patent ductus arteriosus. An echocardiogram from 09/13/2007 demonstrated a 3.8-mm patent ductus arteriosus with restrictive left-to-right shunt. There is mild left atrial chamber enlargement with an LA/AO ratio of 1.821. An electrocardiogram demonstrated normal sinus rhythm with possible left atrial enlargement and left ventricular hypertrophy. The patient underwent cardiac catheterization for device closure of a ductus arteriosus.,PROCEDURE: ,After sedation and local Xylocaine anesthesia, the patient was prepped and draped. Cardiac catheterization was performed as outlined in the attached continuation sheets. Vascular entry was by percutaneous technique, and the patient was heparinized. Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 5-French sheath, a 5-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures up to the branch pulmonary arteries. The atrial septum was not probe patent.,Using a 4-French sheath, a 4-French marker pigtail catheter was inserted into the right femoral artery advanced retrograde to the descending aorta, ascending aorta, and left ventricle. A descending aortogram demonstrated a small, type A patent ductus arteriosus with a small left-to-right angiographic shunt. Minimal diameter was approximately 1.6 mm with ampulla diameter of 5.8 mm and length of 6.2 mm. The wedge catheter could be directed from the main pulmonary artery across the ductus arteriosus to the descending aorta. This catheter exchanged over wire for a 5-French nit-occlude delivery catheter through which a nit-occlude 6/5 flex coil that was advanced and allowed to reconfigure the descending aorta. Entire system was then brought into the ductal ampulla or one loop of coil was delivered in the main pulmonary artery. Once the stable device configuration was confirmed by fluoroscopy, device was released from the delivery catheter. Hemodynamic measurements and angiogram in the descending aorta were then repeated approximately 10 minutes following device implantation.,Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with injection in the descending aorta.,After angiography, two normal-appearing renal collecting systems were visualized. The catheters and sheaths were removed and topical pressure applied for hemostasis. The patient was returned to the recovery room in satisfactory condition. There were no complications.,DISCUSSION: , Oxygen consumption was assumed to be normal. Mixed venous saturation was normal with a slight increased saturation of the branch pulmonary arteries due to left-to-right shunt through the ductus arteriosus. The left-sided heart was fully saturated. The phasic right-sided and left-sided pressures were normal. The calculated systemic flow was normal and pulmonary flow was slightly increased with a QP:QS ratio of 1:1. Vascular resistances were normal. A cineangiogram with contrast injection in the descending aorta showed a small conical shaped ductus arteriosus with a small left-to-right angiographic shunt. The branch pulmonary arteries appeared normal. There is otherwise a normal left aortic arch.,Following coil embolization of the ductus arteriosus, there is no change in mixed venous saturation. No evidence of residual left-to-right shunt. There is no change in right-sided pressures. There is a slight increase in the left-sided phasic pressures. Calculated systemic flow was unchanged from the resting state and pulmonary flow was similar with a QP:QS ratio of 1:1. Final angiogram with injection in the descending aorta showed a majority of coil mass to be within the ductal ampulla with minimal protrusion in the descending aorta as well as the coil in the main pulmonary artery. There is a trace residual shunt through the center of coil mass.,INITIAL DIAGNOSES:, Patent ductus arteriosus.,SURGERIES (INTERVENTIONS): ,Coil embolization of patent ductus arteriosus.,MANAGEMENT: ,The case to be discussed at Combined Cardiology/Cardiothoracic Surgery case conference. The patient will require a cardiologic followup in 6 months and 1 year's time including clinical evaluation and echocardiogram. Further patient care be directed by Dr. X.,

cardiovascular / pulmonary, cardiac murmur, coil embolization, cineangiograms, patent ductus arteriosus, pulmonary artery, patent ductus, descending aorta, ductus, arteriosus, catheterization

Six-month follow-up visit for paroxysmal atrial fibrillation (PAF). She reports that she is getting occasional chest pains with activity. Sometimes she feels that at night when she is lying in bed and it concerns her.

Cardiovascular / Pulmonary

PAF - 6-Month Followup

REASON FOR VISIT:, Six-month follow-up visit for paroxysmal atrial fibrillation (PAF).,She reports that she is getting occasional chest pains with activity. Sometimes she feels that at night when she is lying in bed and it concerns her.,She is frustrated by her inability to lose weight even though she is hyperthyroid.,MEDICATIONS: , Tapazole 10 mg b.i.d., atenolol/chlorthalidone 50/25 mg b.i.d., Micro-K 10 mEq q.d., Lanoxin 0.125 mg q.d., spironolactone 25 mg q.d., Crestor 10 mg q.h.s., famotidine 20 mg, Bayer Aspirin 81 mg q.d., Vicodin p.r.n., and Nexium 40 mg-given samples of this today.,REVIEW OF SYSTEMS:, No palpitations. No lightheadedness or presyncope. She is having mild pedal edema, but she drinks a lot of fluid.,PEX: , BP: 112/74. PR: 70. WT: 223 pounds (up three pounds). Cardiac: Regular rate and rhythm with a 1/6 murmur at the upper sternal border. Chest: Nontender. Lungs: Clear. Abdomen: Moderately overweight. Extremities: Trace edema.,EKG: , Sinus bradycardia at 58 beats per minute, mild inferolateral ST abnormalities.,IMPRESSION:,1. Chest pain-Mild. Her EKG is mildly abnormal. Her last stress echo was in 2001. I am going to have her return for one just to make sure it is nothing serious. I suspect; however, that is more likely due to her weight and acid reflux. I gave her samples of Nexium.,2. Mild pedal edema-Has to cut down on fluid intake, weight loss will help as well, continue with the chlorthalidone.,3. PAF-Due to hypertension, hyperthyroidism and hypokalemia. Staying in sinus rhythm.,4. Hyperthyroidism-Last TSH was mildly suppressed, she had been out of her Tapazole for a while, now back on it.,5. Dyslipidemia-Samples of Crestor given.,6. LVH.,7. Menometrorrhagia.,PLAN:,1. Return for stress echo.,2. Reduce the fluid intake to help with pedal edema.,3. Nexium trial.

cardiovascular / pulmonary, atrial fibrillation, ekg, paroxysmal atrial fibrillation, chest pains, pedal edema, hyperthyroidism, paf, atrial,

The patient is an 84-year-old female presented to emergency room with shortness of breath, fatigue, and tiredness. Low-grade fever was noted last few weeks. The patient also has chest pain described as dull aching type in precordial region. No relation to exertion or activity. No aggravating or relieving factors.

Cardiovascular / Pulmonary

Pericardial Effusion

REASON FOR CONSULTATION:, Pericardial effusion.,HISTORY OF PRESENT ILLNESS: , The patient is an 84-year-old female presented to emergency room with shortness of breath, fatigue, and tiredness. Low-grade fever was noted last few weeks. The patient also has chest pain described as dull aching type in precordial region. No relation to exertion or activity. No aggravating or relieving factors. A CT of the chest was done, which shows pericardial effusion. This consultation is for the same. The patient denies any lightheadedness or dizziness. No presyncope or syncope. Activity is fairly stable.,CORONARY RISK FACTORS: , History of borderline hypertension. No history of diabetes mellitus. Nonsmoker. Cholesterol status is within normal limits. No history of established coronary artery disease. Family history noncontributory.,FAMILY HISTORY: , Nonsignificant.,PAST SURGICAL HISTORY: ,Hysterectomy and bladder surgery.,MEDICATIONS AT HOME: ,Aspirin and thyroid supplementation.,ALLERGIES:, None.,PERSONAL HISTORY:, She is a nonsmoker. She does not consume alcohol. No history of recreational drug use.,PAST MEDICAL HISTORY:,1. Hypothyroidism.,2. Borderline hypertension.,3. Arthritis.,4. Presentation at this time with chest pain and shortness of breath.,REVIEW OF SYSTEMS,CONSTITUTIONAL: Weakness, fatigue, and tiredness.,HEENT: No history of cataract, blurring of vision, or glaucoma.,CARDIOVASCULAR: Chest pain. No congestive heart failure. No arrhythmia.,RESPIRATORY: No history of pneumonia in the past, valley fever.,GASTROINTESTINAL: Epigastric discomfort. No hematemesis or melena.,UROLOGICAL: Frequency. No urgency. No hematuria.,MUSCULOSKELETAL: Arthritis and muscle weakness.,CNS: No TIA. No CVA. No seizure disorder.,ENDOCRINE: Nonsignificant.,HEMATOLOGICAL: Nonsignificant.,PHYSICAL EXAMINATION,VITAL SIGNS: Pulse of 86, blood pressure 93/54, afebrile, respiratory rate 16 per minute.,HEENT: Atraumatic and normocephalic.,NECK: Supple. Neck veins flat. No significant carotid bruit.,LUNGS: Air entry bilaterally fair.,HEART: PMI displaced. S1 and S2 regular.,ABDOMEN: Soft and nontender.,EXTREMITIES: No edema. Pulses palpable. No clubbing or cyanosis.,CNS: Grossly intact.,LABORATORY DATA: ,White count of 20 and H&H 13 and 39. BUN and creatinine within normal limits. Cardiac enzyme profile negative.,RADIOGRAPHIC STUDIES: , CT of the chest preliminary report, pericardial effusion. Echocardiogram shows pericardial effusion, which appears to be chronic. There is no evidence of hemodynamic compromise.,IMPRESSION:,1. The patient is an 84-year-old female admitted with chest pain and shortness of breath, possibly secondary to pulmonary disorder. She has elevated white count, possible infection.,2. Pericardial effusion without any hemodynamic compromise, could be chronic.

Ligation (clip interruption) of patent ductus arteriosus. This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch.

Cardiovascular / Pulmonary

Patent Ductus Arteriosus Ligation

TITLE OF OPERATION: , Ligation (clip interruption) of patent ductus arteriosus.,INDICATION FOR SURGERY: , This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch. She has now been put forward for operative intervention.,PREOP DIAGNOSIS: ,1. Patent ductus arteriosus.,2. Severe prematurity.,3. Operative weight less than 4 kg (600 grams).,COMPLICATIONS: , None.,FINDINGS: , Large patent ductus arteriosus with evidence of pulmonary over circulation. After completion of the procedure, left recurrent laryngeal nerve visualized and preserved. Substantial rise in diastolic blood pressure.,DETAILS OF THE PROCEDURE: , After obtaining information consent, the patient was positioned in the neonatal intensive care unit, cribbed in the right lateral decubitus, and general endotracheal anesthesia was induced. The left chest was then prepped and draped in the usual sterile fashion and a posterolateral thoracotomy incision was performed. Dissection was carried through the deeper planes until the second intercostal space was entered freely with no damage to the underlying lung parenchyma. The lung was quite edematous and was retracted anteriorly exposing the area of the isthmus. The pleura overlying the ductus arteriosus was inside and the duct dissected in a nearly circumferential fashion. It was then test occluded and then interrupted with a medium titanium clip. There was preserved pulsatile flow in the descending aorta. The left recurrent laryngeal nerve was identified and preserved. With excellent hemostasis, the intercostal space was closed with 4-0 Vicryl sutures and the muscular planes were reapproximated with 5-0 Caprosyn running suture in two layers. The skin was closed with a running 6-0 Caprosyn suture. A sterile dressing was placed. Sponge and needle counts were correct times 2 at the end of the procedure. The patient was returned to the supine position in which palpable bilateral femoral pulses were noted.,I was the surgical attending present in the neonatal intensive care unit and in-charge of the surgical procedure throughout the entire length of the case.

cardiovascular / pulmonary, clip interruption, ligation, patent ductus arteriosus, premature baby, intercostal space, arteriosus, interruption, pulmonary, circulation

PICC line insertion

Cardiovascular / Pulmonary

PICC line insertion

PROCEDURE PERFORMED:, PICC line insertion.,DESCRIPTION OF PROCEDURE:, The patient was identified by myself on presentation to the angiography suite. His right arm was prepped and draped in sterile fashion from the antecubital fossa up. Under ultrasound guidance, a #21-gauge needle was placed into his right cephalic vein. A guidewire was then threaded through the vein and advanced without difficulty. An introducer was then placed over the guidewire. We attempted to manipulate the guidewire to the superior vena cava; however, we could not pass the point of the subclavian vein and we tried several maneuvers and then opted to do a venogram. What we did was we injected approximately 4 mL of Visipaque 320 contrast material through the introducer and did a mapping venogram and it turned out that the cephalic vein was joining into the subclavian vein. It was very tortuous area. We made several more attempts using the mapping system to pass the glide over that area, but we were unable to do that. Decision was made at that point then to just do a midline catheter. The catheter was cut to 20 cm, then we inserted back to the introducer. The introducer was removed. The catheter was secured by two #3-0 silk sutures. Appropriate imaging was then taken. Sterile dressing was applied. The patient tolerated the procedure nicely and was discharged from Angiography in satisfactory condition back to the general floor. We may make another attempt in the near future using a different approach.,

cardiovascular / pulmonary, picc, picc line, angiography, guidewire, superior vena cava, subclavian vein, venogramNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

Peripheral effusion on the CAT scan. The patient is a 70-year-old Caucasian female with prior history of lung cancer, status post upper lobectomy. She was recently diagnosed with recurrent pneumonia and does have a cancer on the CAT scan, lung cancer with metastasis.

Cardiovascular / Pulmonary

Peripheral Effusion - Consult

REASON FOR CONSULT: , Peripheral effusion on the CAT scan.,HISTORY OF PRESENT ILLNESS: , The patient is a 70-year-old Caucasian female with prior history of lung cancer, status post upper lobectomy. She was recently diagnosed with recurrent pneumonia and does have a cancer on the CAT scan, lung cancer with metastasis. The patient had a visiting nurse for Christmas and started having abdominal pain, nausea and vomiting for which, she was admitted. She had a CAT scan of the abdomen done, showed moderate pericardial effusion for which cardiology consult was requested. She had an echo done, which shows moderate pericardial effusion with early tamponade. The patient has underlying shortness of breath because of COPD, emphysema and chronic cough. However, denies any dizziness, syncope, presyncope, palpitation. Denies any prior history of coronary artery disease.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , At this time, she is on hydromorphone p.r.n., erythromycin, ceftriaxone, calcium carbonate, Ambien. She is on oxygen and nebulizer.,PAST MEDICAL HISTORY: , History of COPD, emphysema, pneumonia, and lung cancer.,PAST SURGICAL HISTORY: ,Hip surgery and resection of the lung cancer 10 years ago.,SOCIAL HISTORY:, Still smokes, but less than before. Drinks socially.,FAMILY HISTORY:, Noncontributory.,REVIEW OF SYSTEMS: , Denies any syncope, presyncope, palpitations, shortness of breath, cough, nausea, vomiting, or diarrhea.,PHYSICAL EXAMINATION:,GENERAL: The patient is comfortable not in any distress.,VITAL SIGNS: Blood pressure 121/79, Pulse rate 94, respiratory rate 19, and temperature 97.6.,HEENT: Atraumatic and normocephalic.,NECK: Supple. No JVD. No carotid bruit.,CHEST: Breath sounds vesicular. Clear on auscultation.,HEART: PMI could not be localized. S2 and S2 regular. No S3, no S4. No murmur.,ABDOMEN: Soft and nontender. Positive bowel sounds.,EXTREMITIES: No cyanosis, clubbing, or edema. Pulse 2+.,CNS: Alert, awake, and oriented x3.,EKG shows normal sinus rhythm, low voltage.,LABORATORY DATA: , White cell count 7.3, hemoglobin 12.9, hematocrit 38.1, and platelet at 322,000. Sodium 135, potassium 5, BUN 6, creatinine 1.2, glucose 71, alkaline phosphatase 263, total protein 5.3, lipase 414, and amylase 57.,DIAGNOSTIC STUDIES:, Chest x-ray shows left upper lobe airspace disease consistent with pneumonia _______. CT abdomen showed diffuse replacement of the _______ metastasis, hepatomegaly, perihepatic ascites, moderate pericardial effusion, small left _______ sigmoid diverticulosis.,ASSESSMENT:,1. Moderate peripheral effusion with early tamponade, probably secondary to lung cancer.,2. Lung cancer with metastasis most likely.,3. Pneumonia.,4. COPD.,PLAN: , We will get CT surgery consult for pericardial window. Continue present medication.

Sinus bradycardia, sick-sinus syndrome, poor threshold on the ventricular lead and chronic lead. Right ventricular pacemaker lead placement and lead revision.

Cardiovascular / Pulmonary

Pacemaker Lead Placement & Rrevision.

PROCEDURE: , Right ventricular pacemaker lead placement and lead revision.,INDICATIONS:, Sinus bradycardia, sick-sinus syndrome, poor threshold on the ventricular lead and chronic lead.,EQUIPMENT: , A new lead is a Medtronic model #12345, threshold sensing at 5.7, impedance of 1032, threshold of 0.3, atrial threshold is 0.3, 531, and sensing at 4.1. The original chronic ventricular lead had a threshold of 3.5 and 6 on the can.,ESTIMATED BLOOD LOSS: , 5 mL.,PROCEDURE DESCRIPTION: ,Conscious sedation with Versed and fentanyl over left subclavicular area with pacemaker pocket was anesthetized with local anesthetic with epinephrine. The patient received a venogram documenting patency of the subclavian vein. Skin incision with blunt and sharp dissection. Electrocautery for hemostasis. The pocket was opened and the pacemaker was removed from the pocket and disconnected from the leads. The leads were sequentially checked. Through the pocket a puncture of the vein with a thin wall needle was made and a long sheath was used to help carry it along the tortuosity of the proximal subclavian and innominate superior vena cava. Ultimately, a ventricular lead was placed in apex of the right ventricle, secured to base pocket with 2-0 silk suture. Pocket was irrigated with antibiotic solution. The pocket was packed with bacitracin-soaked gauze. This was removed during the case and then irrigated once again. The generator was attached to the leads, placed in the pocket, secured with 2-0 silk suture and the pocket was closed with a three layer of 4-0 Monocryl.,CONCLUSION: , Successful replacement of a right ventricular lead secondary to poor lead thresholds in a chronic lead and placement of the previous Vitatron pulse generator model # 12345.

cardiovascular / pulmonary, medtronic, atrial, subclavian, sick sinus syndrome, pacemaker lead placement, ventricular pacemaker, ventricular lead, lead, bradycardia, pacemaker, threshold, ventricular

Nuclear cardiac stress report. Recurrent angina pectoris in a patient with documented ischemic heart disease and underlying ischemic cardiomyopathy.

Cardiovascular / Pulmonary

Nuclear Cardiac Stress Report

NUCLEAR CARDIOLOGY/CARDIAC STRESS REPORT,INDICATION FOR STUDY: , Recurrent angina pectoris in a patient with documented ischemic heart disease and underlying ischemic cardiomyopathy.,PROCEDURE: , The patient was studied in the resting state following intravenous delivery of adenosine triphosphate at 140 mcg/kg/min delivered over a total of 4 minutes. At completion of the second minute of infusion, the patient received technetium Cardiolite per protocol. During this interval, the blood pressure 150/86 dropped to near 136/80 and returned to near 166/84 at completion. No diagnostic electrocardiographic abnormalities were elaborated during this study.,REGIONAL MYOCARDIAL PERFUSION WITH ADENOSINE PROVOCATION: , Scintigraphic study reveals at this time multiple fixed defects in perfusion suggesting indeed multivessel coronary artery disease, yet no active ischemia at this time. A fixed defect is seen in the high anterolateral segment. A further fixed perfusion defect is seen in the inferoapical wall extending from close to the septum. There is no evidence for active ischemia in either distribution. Lateral wall moving towards the apex of the left ventricle is further involved from midway through the ventricle moving upward and into the high anterolateral vicinity. When viewed from the vertical projection, the high septal wall is preserved with significant loss of the mid anteroapical wall moving to the apex and in a wraparound fashion in the inferoapical wall. A limited segment of apical myocardium is still viable.,No gated wall motion study was obtained.,CONCLUSIONS: ,Cardiolite perfusion findings support multivessel coronary artery disease and likely previous multivessel infarct as has been elaborated above. There is no indication for active ischemia at this time.

cardiovascular / pulmonary, angina pectoris, ischemic cardiomyopathy, myocardial perfusion, adenosine provocation, cardiolite perfusion, nuclear cardiac stress report, coronary artery disease, active ischemia, ischemic, angina,

Implantation of a dual-chamber pacemaker and fluoroscopic guidance for implantation of a dual-chamber pacemaker.

Cardiovascular / Pulmonary

Pacemaker (Dual Chamber) - 1

PREPROCEDURE DIAGNOSIS: , Complete heart block.,POSTPROCEDURE DIAGNOSIS: ,Complete heart block.,PROCEDURES PLANNED AND PERFORMED,1. Implantation of a dual-chamber pacemaker.,2. Fluoroscopic guidance for implantation of a dual-chamber pacemaker.,FLUOROSCOPY TIME: , 2.6 minutes.,MEDICATIONS AT THE TIME OF STUDY,1. Versed 2.5 mg.,2. Fentanyl 150 mcg.,3. Benadryl 50 mg.,CLINICAL HISTORY: , the patient is a pleasant 80-year-old female who presented to the hospital with complete heart block. She has been referred for a pacemaker implantation.,RISKS AND BENEFITS: , Risks, benefits, and alternatives to implantation of a dual-chamber pacemaker were discussed with the patient. The patient agreed both verbally and via written consent.,DESCRIPTION OF PROCEDURE: , The patient was transported to the cardiac catheterization laboratory in the fasting state. The region of the left deltopectoral groove was prepped and draped in the usual sterile manner. Lidocaine 1% (20 mL) was administered to the area. After achieving appropriate anesthesia, percutaneous access of the left axillary vein was then performed under fluoroscopy. A guide wire was advanced into the vein. Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath. Hemostasis was achieved with electrocautery. Lidocaine 1% (10 mL) was then administered to the medial aspect of the incision. A pocket was then fashioned in the medial direction. Using the previously placed wire, a 7-French side-arm sheath was advanced over the wire into the left axillary vein. The dilator was then removed over the wire. A second wire was then advanced into the sheath into the left axillary vein. The sheath was then removed over the top of the two wires. One wire was then pinned to the drape. Using the remaining wire, a 7 French side-arm sheath was advanced back into the left axillary vein. The dilator and wire were removed. A passive pacing lead was then advanced down into the right atrium. The peel-away sheath was removed. The lead was then passed across the tricuspid valve and positioned in the apical location. Adequate pacing and sensing functions were established. Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. With the remaining wire, a 7-French side-arm sheath was advanced over the wire into the axillary vein. The wire and dilating sheaths were removed. An active pacing lead was then advanced down into the right atrium. The peel-away sheath was removed. Preformed J stylet was then advanced into the lead. The lead was positioned in the appendage location. Lead body was then turned, and the active fix screw was fixed to the tissue. Adequate pacing and sensing function were established. Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. The pocket was then washed with antibiotic-impregnated saline. Pulse generator was obtained and connected securely to the leads. The leads were then carefully wrapped behind the pulse generator, and the entire system was placed in the pocket. The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch. Sponge and needle counts were correct at the end of the procedure. No acute complications were noted.,DEVICE DATA,1. Pulse generator, manufacturer Boston Scientific, model # 12345, serial #1234.,2. Right atrial lead, manufacturer Guidant, model #12345, serial #1234.,3. Right ventricular lead, manufacturer Guidant, model #12345, serial #1234.,MEASURED INTRAOPERATIVE DATA,1. Right atrial lead impedance 534 ohms. P waves measured at 1.2 millivolts. Pacing threshold 1.0 volt at 0.5 milliseconds.,2. Right ventricular lead impedance 900 ohms. R-waves measured 6.0 millivolts. Pacing threshold 1.0 volt at 0.5 milliseconds.,DEVICE SETTINGS: , DDD 60 to 130.,CONCLUSIONS,1. Successful implantation of a dual-chamber pacemaker with adequate pacing and sensing function.,2. No acute complications.,PLAN,1. The patient will be taken back to her room for continued observation. She can be dismissed in 24 hours provided no acute complications at the discretion of the primary service.,2. Chest x-ray to rule out pneumothorax and verified lead position.,3. Completion of the course of antibiotics.,4. Home dismissal instructions provided in written format.,5. Device interrogation in the morning.,6. Wound check in 7 to 10 days.,7. Enrollment in device clinic.

Insertion of transvenous pacemaker for tachybrady syndrome

Cardiovascular / Pulmonary

Pacemaker Insertion

PREOPERATIVE DIAGNOSIS:, Tachybrady syndrome.,POSTOPERATIVE DIAGNOSIS:, Tachybrady syndrome.,OPERATIVE PROCEDURE:, Insertion of transvenous pacemaker.,ANESTHESIA:, Local,PROCEDURE AND GROSS FINDINGS:, The patient's chest was prepped with Betadine solution and a small amount of Lidocaine infiltrated. In the left subclavian region, a subclavian stick was performed without difficulty, and a wire was inserted. Fluoroscopy confirmed the presence of the wire in the superior vena cava. An introducer was then placed over the wire. The wire was removed and replace by a ventricular lead that was seated under Fluoroscopy. Following calibration, the lead was attached to a pacemaker generator that was inserted in a subcutaneous pocket in the left subclavian area. ,The subcutaneous tissues were irrigated and closed with Interrupted 4-O Vicryl, and the skin was closed with staples. Sterile dressings were placed, and the patient was returned to the ICU in good condition.

cardiovascular / pulmonary, insertion of transvenous pacemaker, fluoroscopy, tachybrady, tachybrady syndrome, chest, pacemaker, subclavian, subcutaneous, superior vena cava, syndrome, transvenous pacemaker, wire, insertion,

DDDR permanent pacemaker. Tachybrady syndrome. A ventricular pacemaker lead was advanced through the sheath and into the vascular lumen and under fluoroscopic guidance guided down into the right atrium.

Cardiovascular / Pulmonary

Pacemaker - DDDR

PROCEDURE PERFORMED: ,DDDR permanent pacemaker.,INDICATION: , Tachybrady syndrome.,PROCEDURE:, After all risks, benefits, and alternatives of the procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing. The patient was taken to the Cardiac Catheterization Suite where the right subclavian region was prepped and draped in the usual sterile fashion. 1% lidocaine solution was used to infiltrate the skin overlying the left subclavian vein. Once adequate anesthesia had been obtained, a thin-walled #18-gauze Argon needle was used to cannulate the left subclavian vein. A steel guidewire was inserted through the needle into the vascular lumen without resistance. The needle was then removed over the guidewire and the guidewire was secured to the field. A second #18 gauze Argon needle was used to cannulate the left subclavian vein and once again a steel guidewire was inserted through the needle into the vascular lumen. Likewise, the needle was removed over the guidewire and the guidewire was then secured to the field. Next, a #15-knife blade was used to make a 1 to 1.5 inch linear incision over the area. A #11-knife blade was used to make a deeper incision. Hemostasis was made complete. The edges of the incision were grasped and retracted. Using Metzenbaum scissors, dissection was carried down to the pectoralis muscle fascial plane. Digital blunt dissection was used to make a pacemaker pocket large enough to accommodate the pacemaker generator. Metzenbaum scissors were then used to dissect cephalad to expose the guide wires. The guidewires were then pulled through the pacemaker pocket. One guidewire was secured to the field.,A bloodless introducer sheath was then advanced over a guidewire into the vascular lumen under fluoroscopic guidance. The guidewire and dilator were then removed. Next, a ventricular pacemaker lead was advanced through the sheath and into the vascular lumen and under fluoroscopic guidance guided down into the right atrium. The pacemaker lead was then placed in the appropriate position in the right ventricle. Pacing and sensing thresholds were obtained. The lead was sewn at the pectoralis muscle plane using #2-0 silk suture in an interrupted stitch fashion around the ________. Pacing and sensing threshold were then reconfirmed. Next, a second bloodless introducer sheath was advanced over the second guidewire into the vascular lumen. The guidewire and dilator were then removed. Under fluoroscopic guidance, the atrial lead was passed into the right atrium. The sheath was then turned away in standard fashion. Using fluoroscopic guidance, the atrial lead was then placed in the appropriate position. Pacing and sensing thresholds were obtained. The lead was sewn to the pectoralis muscle facial plane utilizing #2-0 silk suture around the ________. Sensing and pacing thresholds were then reconfirmed. The leads were wiped free of blood and placed into the pacemaker generator. The pacemaker generator leads were then placed into pocket with the leads posteriorly. The deep tissues were closed utilizing #2-0 Chromic suture in an interrupted stitch fashion. A #4-0 undyed Vicryl was then used to close the subcutaneous tissue in a continuous subcuticular stitch. Steri-Strips overlaid. A sterile gauge dressing was placed over the site. The patient tolerated the procedure well and was transferred to the Cardiac Catheterization Room in stable and satisfactory condition.,PACEMAKER DATA (GENERATOR DATA):,Manufacturer: Medtronics.,Model: Sigma.,Model #: 1234.,Serial #: 123456789.,LEAD INFORMATION:,Right Atrial Lead:,Manufacturer: Medtronics.,Model #: 1234.,Serial #: 123456789.,VENTRICULAR LEAD:,Manufacturer: Medtronics.,Model #: 1234.,Serial #: 123456789.,PACING AND SENSING THRESHOLDS:,Right Atrial Bipolar Lead: Pulse width 0.50 milliseconds, impedance 518 ohms, P-wave sensing 2.2 millivolts, polarity is bipolar.,Ventricular Bipolar Lead: Pulse width 0.50 milliseconds, voltage 0.7 volts, current 1.5 milliamps, impedance 655 ohms, R-wave sensing 9.7 millivolts, polarity is bipolar.,PARAMETER SETTINGS:, Pacing mode DDDR: Mode switch is on, low rate 60, upper 120, ________ is 33.0 milliseconds.,IMPRESSION:, Successful implantation of DDDR permanent pacemaker.,PLAN:,1. The patient will be monitored on telemetry for 24 hours to ensure adequate pacemaker function.,2. The patient will be placed on antibiotics for five days to avoid pacemaker infection.

Implantation of a single-chamber pacemaker. Fluoroscopic guidance for implantation of single-chamber pacemaker.

Cardiovascular / Pulmonary

Pacemaker (Single Chamber) - 1

REFERRAL INDICATION,1. Tachybrady syndrome.,2. Chronic atrial fibrillation.,PROCEDURES PLANNED AND PERFORMED,1. Implantation of a single-chamber pacemaker.,2. Fluoroscopic guidance for implantation of single-chamber pacemaker.,FLUOROSCOPY TIME: ,1.2 minutes.,MEDICATIONS AT THE TIME OF STUDY,1. Ancef 1 g.,2. Benadryl 50 mg.,3. Versed 3 mg.,4. Fentanyl 150 mcg.,CLINICAL HISTORY: , The patient is a pleasant 73-year-old female with chronic atrial fibrillation. She has been found to have tachybrady syndrome, has been referred for pacemaker implantation.,RISKS AND BENEFITS: , Risks, benefits, and alternatives of implantation of a single-chamber pacemaker were discussed with the patient. The patient agreed both verbally and via written consent. Risks that were discussed included but were not limited to bleeding, infection, vascular injury, cardiac perforation, stroke, myocardial infarction, need for urgent cardiovascular surgery, and death were discussed with the patient. The patient agreed both verbally and via written consent.,DESCRIPTION OF PROCEDURE: , The patient was transported to the cardiac catheterization laboratory in a fasting state. The region of the left deltopectoral groove was prepped and draped in the usual sterile manner. Lidocaine 1% (20 mL) was administered to the area. Percutaneous access of the left axillary vein was then performed. A wire was then advanced in the left axillary vein using fluoroscopy. Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath. Lidocaine 1% (10 mL) was then administered to the medial aspect of the incision and a pocket was fashioned in the medial direction. Using the previously placed guidewire, a 7-French sidearm sheath was advanced over the wire into the vein. The dilator and wire were removed. An active pacing lead was then advanced down in the right atrium. The peel-away sheath was removed. Lead was passed across the tricuspid valve and positioned in an apical septal location. This was an active fixed lead and the screw was deployed. Adequate pacing and sensing function were established. The suture sleeve was then advanced to the entry point of the tissue and connected securely to the tissue. The pocket was washed with antibiotic-impregnated saline. A pulse generator was obtained and connected securely to the lead. The lead was then carefully wrapped behind the pulse generator, and the entire system was placed in the pocket. Pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch. No acute complications were noted.,DEVICE DATA,1. Pulse generator, manufacturer St. Jude model 12345, serial #123456.,2. Right ventricular lead, manufacturer St. Jude model 12345, serial #ABCD123456.,MEASURED INTRAOPERATIVE DATA:, Right ventricular lead impedance 630 ohms. R wave measures 17.5 mV. Pacing threshold of 0.8 V at 0.5 msec.,DEVICE SETTINGS: , VVI 70 to 120.,CONCLUSIONS,1. Successful implantation of the single-chamber pacemaker with adequate pacing and sensing function.,2. No acute complications.,PLAN,1. The patient will be admitted for overnight observation and dismissed at the discretion of primary service.,2. Chest x-ray to rule out pneumothorax and verify lead position.,3. Completion of course of antibiotics.,4. Device interrogation in the morning.,5. Home dismissal instructions provided in a written format.,6. Wound check in 7 to 10 days.,7. Enrollment in Device Clinic.

Pacemaker ICD interrogation. Severe nonischemic cardiomyopathy with prior ventricular tachycardia.

Cardiovascular / Pulmonary

Pacemaker Interrogation

PROCEDURE NOTE: , Pacemaker ICD interrogation.,HISTORY OF PRESENT ILLNESS: , The patient is a 67-year-old gentleman who was admitted to the hospital. He has had ICD pacemaker implantation. This is a St. Jude Medical model current DRRS, 12345 pacemaker.,DIAGNOSIS: , Severe nonischemic cardiomyopathy with prior ventricular tachycardia.,FINDINGS: , The patient is a DDD mode base rate of 60, max tracking rate of 110 beats per minute, atrial lead is set at 2.5 volts with a pulse width of 0.5 msec, ventricular lead set at 2.5 volts with a pulse width of 0.5 msec. Interrogation of the pacemaker shows that atrial capture is at 0.75 volts at 0.5 msec, ventricular capture 0.5 volts at 0.5 msec, sensing in the atrium is 5.34 to 5.8 millivolts, R sensing is 12-12.0 millivolts, atrial lead impendence 590 ohms, ventricular lead impendence 750 ohms. The defibrillator portion is set at VT1 at 139 beats per minute with SVT discrimination on therapy is monitor only. VT2 detection criteria is 169 beats per minute with SVT discrimination on therapy of ATP times 3 followed by 25 joules, followed by 36 joules, followed by 36 joules times 2. VF detection criteria set at 187 beats per minute with therapy of 25 joules, followed by 36 joules times 5. The patient is in normal sinus rhythm.,IMPRESSION: ,Normally functioning pacemaker ICD post implant day number 1.

cardiovascular / pulmonary, cardiomyopathy, ventricular, tachycardia, pacemaker icd interrogation, millivolts, impendence, interrogation, pacemaker,

Single chamber pacemaker implantation. Successful single-chamber pacemaker implantation with left subclavian approach and venogram to assess the subclavian access site and the right atrial or right ventricle with asystole that resolved spontaneously during the procedure.

Cardiovascular / Pulmonary

Pacemaker (Single Chamber)

SINGLE CHAMBER PACEMAKER IMPLANTATION,PREOPERATIVE DIAGNOSIS: , Mobitz type II block with AV dissociation and syncope.,POSTOPERATIVE DIAGNOSIS: , Mobitz type II block, status post single chamber pacemaker implantation, Boston Scientific Altrua 60, serial number 123456.,PROCEDURES:,1. Left subclavian access under fluoroscopic guidance.,2. Left subclavian venogram under fluoroscopic evaluation.,3. Insertion of ventricular lead through left subclavian approach and ventricular lead is Boston Scientific Dextrose model 12345, serial number 123456.,4. Insertion of single-chamber pacemaker implantation, Altrua, serial number 123456.,5. Closure of the pocket after formation of pocket for pacemaker.,PROCEDURE IN DETAIL: ,The procedure was explained to the patient with risks and benefits. The patient agreed and signed the consent form. The patient was brought to the cath lab, draped and prepped in the usual sterile fashion, received 1.5 mg of versed and 25 mg of Benadryl for conscious sedation.,Access to the right subclavian was successful after the second attempt. The first attempt accessed the left subclavian artery. The needle was removed and manual compression applied for five minutes followed by re-accessing the subclavian vein successfully. The J-wire was introduced into the left subclavian vein.,The anterior wall chest was anesthetized with lidocaine 2%, 2-inch incision using a #10 blade was used.,The pocket was formed using blunt dissection as he was using the Bovie cautery for hemostasis. The patient went asystole during the procedure. The transcutaneous pacer was used. The patient was oxygenating well. The patient had several compression applied by the nurse. However, her own rhythm resolved spontaneously and the percutaneous pacer was kept on standby.,After that, the J-wire was tunneled into the pocket and then used to put the #7-French sheath into the left subclavian vein. The lead from the Boston Scientific Dextrose model 12345, serial number 12345 was inserted through the left subclavian to the right atrium; however, it was difficult to really enter the right ventricle; and while the lead was in place, the side port of the sheath was used to inject 15 mL of contrast to assess the subclavian and the right atrium. The findings were showing different anatomy, may be consistent with persistent left superior vena cava, and the angle to the right ventricle was different. At that point, the lead stylet was reshaped and was able to cross the tricuspid valve in a position consistent with the mid septal place.,At that point, the lead was actively fixated. The stylet was removed. The R-wave measured at 40 millivolts. The impedance was 580 and the threshold was 1.3 volt. The numbers were accepted and because of the patient's fragility and the different anatomy noticed in the right atrium, concern about putting a second lead with re-access of the subclavian was high. I decided to proceed with a single-chamber pacemaker as a backup system.,After that, the lead sleeve was used to actively fixate the lead in the anterior chest with two Ethibond sutures in the usual fashion.,The lead was attached to the pacemaker in the header. The pacemaker was single-chamber pacemaker Altura 60, serial number 123456. After that, the pacemaker was put in the pocket. Pocket was irrigated with normal saline and was closed into two layers, deep interrupted #3-0 Vicryl and surface as continuous #4-0 Vicryl continuous.,The pacemaker was programmed as VVI 60, and with history is 10 to 50 beats per minute. The lead position will be evaluated with chest x-ray.,No significant bleeding noticed.,CONCLUSION: ,Successful single-chamber pacemaker implantation with left subclavian approach and venogram to assess the subclavian access site and the right atrial or right ventricle with asystole that resolved spontaneously during the procedure. No significant bleed.

cardiovascular / pulmonary, mobitz, av dissociation, syncope, mobitz type ii block, boston scientific altrua, subclavian, venogram, ventricular, single chamber pacemaker implantation, single chamber pacemaker, pacemaker implantation, pacemaker, vein, chest, atrium, ventricle, atrial, implantation, chamber,

A patient with non-Q-wave myocardial infarction. No definite chest pains. The patient is breathing okay. The patient denies orthopnea or PND.

Cardiovascular / Pulmonary

Non-Q-wave Myocardial Infarction

REASON FOR CONSULT: , A patient with non-Q-wave myocardial infarction.,HISTORY OF PRESENT ILLNESS: , The patient is a pleasant 52-year-old gentleman with a history of diabetes mellitus, hypertension, and renal failure, on dialysis, who presented with emesis, dizziness, and nausea for the last few weeks. The patient reports having worsening emesis and emesis a few times. No definite chest pains. The patient is breathing okay. The patient denies orthopnea or PND.,PAST MEDICAL HISTORY:,1. Diabetes mellitus.,2. Hypertension.,3. Renal failure, on dialysis.,MEDICATIONS:, Aspirin, Coreg, doxazosin, insulin, metoclopramide, simvastatin, and Starlix.,ALLERGIES: ,NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient denies tobacco, alcohol or drug use.,FAMILY HISTORY: , Negative for early atherosclerotic heart disease.,REVIEW OF SYSTEMS: , General: The patient denies fever or chills. Pulmonary: The patient denies hemoptysis. Cardiovascular: Refer to HPI. GI: The patient denies hematemesis or melena. The rest of systems review is negative.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse 71, blood pressure 120/70, and respiratory rate 18.,GENERAL: A well-nourished, well-developed male in no acute distress.,HEENT: Normocephalic, atraumatic. Pupils seem to be equal, round, and reactive. Extraocular muscles are full, but the patient has left eye ptosis.,NECK: Supple without JVD or lymphadenopathy.,LUNGS: Clear to auscultation bilaterally.,CARDIOVASCULAR: PMI is displaced 0.5 cm lateral to the midclavicular line. Regular rate and rhythm, S1, S2. No definite S3, 2/6 holosystolic murmur at the apex radiating to the axilla.,ABDOMEN: Positive bowel sounds, nondistended and nontender. No hepatosplenomegaly.,EXTREMITIES: Trace pedal edema.,EKG shows atrial fibrillation with rapid ventricular response at 164 with old anteroseptal myocardial infarction and old inferior wall myocardial infarction. Subsequent EKG in sinus rhythm shows sinus rhythm with old inferior wall myocardial infarction and probable anteroseptal myocardial infarction with Q-waves in V1, V2, and up to V3.,LABORATORY EXAM: , WBC 28,800, hemoglobin 13.6, hematocrit 40, and platelets 266,000. PT 11.3, INR 1.1, and PTT 24.1. Sodium 126, potassium 4.3, chloride 86, CO2 26, glucose 371, BUN 80, and creatinine 8.4. CK was 261, then 315, and then 529 with CK-MB of 8.06, then 8.69, and then 24.6. Troponin was 0.051, then 0.46, and then 19.8 this morning.,IMPRESSION:,1. Paroxysmal atrial fibrillation. The heart rate was slowed down with IV Cardizem, the patient converted to sinus rhythm. The patient is currently in sinus rhythm.,2. Emesis. The etiology is unclear. The patient reports that the emesis is better. The patient is just having some nausea.,3. Non-Q-wave myocardial infarction. EKG shows atrial fibrillation with old anteroseptal myocardial infarction and old inferior wall myocardial infarction.,4. Diabetes mellitus.,5. Renal failure.,6. Hypertension.,7. Hypercholesterolemia.,PLAN:,1. We will start amiodarone to keep from going back into atrial fibrillation.,2. Echocardiogram.,3. Aspirin and IV heparin.,4. Serial CK-MB and troponin.,5. Cardiac catheterization, possible percutaneous coronary intervention. The risks, benefits, and alternatives were explained to the patient through a translator. The patient understands and wishes to proceed.,6. IV Integrilin.

Implantation of a dual chamber permanent pacemaker

Cardiovascular / Pulmonary

Pacemaker (Dual Chamber)

CLINICAL HISTORY: ,This 78-year-old black woman has a history of hypertension, but no other cardiac problems. She noted complaints of fatigue, lightheadedness, and severe dyspnea on exertion. She was evaluated by her PCP on January 31st and her ECG showed sinus bradycardia with a rate of 37 beats per minute. She has had intermittent severe sinus bradycardia alternating with a normal sinus rhythm, consistent with sinoatrial exit block, and she is on no medications known to cause bradycardia. An echocardiogram showed an ejection fraction of 70% without significant valvular heart disease.,PROCEDURE:, Implantation of a dual chamber permanent pacemaker.,APPROACH:, Left cephalic vein.,LEADS IMPLANTED: ,Medtronic model 12345 in the right atrium, serial number 12345. Medtronic 12345 in the right ventricle, serial number 12345.,DEVICE IMPLANTED: ,Medtronic EnRhythm model 12345, serial number 12345.,LEAD PERFORMANCE: ,Atrial threshold less than 1.3 volts at 0.5 milliseconds. P wave 3.3 millivolts. Impedance 572 ohms. Right ventricle threshold 0.9 volts at 0.5 milliseconds. R wave 10.3. Impedance 855.,ESTIMATED BLOOD LOSS:, 20 mL.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the electrophysiology laboratory in a fasting state and intravenous sedation was provided as needed with Versed and fentanyl. The left neck and chest were prepped and draped in the usual manner and the skin and subcutaneous tissues below the left clavicle were infiltrated with 1% lidocaine for local anesthesia. A 2-1/2-inch incision was made below the left clavicle and electrocautery was used for hemostasis. Dissection was carried out to the level of the pectoralis fascia and extended caudally to create a pocket for the pulse generator. The deltopectoral groove was explored and a medium-sized cephalic vein was identified. The distal end of the vein was ligated and a venotomy was performed. Two guide wires were advanced to the superior vena cava and peel-away introducer sheaths were used to insert the two pacing leads. The venous pressures were elevated and there was a fair amount of back-bleeding from the vein, so a 3-0 Monocryl figure-of-eight stitch was placed around the tissue surrounding the vein for hemostasis. The right ventricular lead was placed in the high RV septum and the right atrial lead was placed in the right atrial appendage. The leads were tested with a pacing systems analyzer and the results are noted above. The leads were then anchored in place with #0-silk around their suture sleeve and connected to the pulse generator. The pacemaker was noted to function appropriately. The pocket was then irrigated with antibiotic solution and the pacemaker system was placed in the pocket. The incision was closed with two layers of 3-0 Monocryl and a subcuticular closure of 4-0 Monocryl. The incision was dressed with Steri-Strips and a sterile bandage and the patient was returned to her room in good condition.,IMPRESSION: ,Successful implantation of a dual chamber permanent pacemaker via the left cephalic vein. The patient will be observed overnight and will go home in the morning.

cardiovascular / pulmonary, medtronic enrhythm, cephalic vein, dual chamber, dual chamber permanent pacemaker, dyspnea on exertion, echocardiogram, fatigue, hypertension, lightheadedness, normal sinus rhythm, pacemaker, permanent pacemaker, sinoatrial exit block, sinus bradycardia, valvular heart disease, bradycardia, medtronic, atrial,

Myocardial perfusion imaging - patient with history of MI, stents placement, and chest pain.

Cardiovascular / Pulmonary

Myocardial Perfusion Imaging - 1

MEDICATIONS: , Plavix, atenolol, Lipitor, and folic acid.,CLINICAL HISTORY: ,This is a 41-year-old male patient who comes in with chest pain, had had a previous MI in 07/2003 and stents placement in 2003, who comes in for a stress myocardial perfusion scan.,With the patient at rest, 10.3 mCi of Cardiolite technetium-99 m sestamibi was injected and myocardial perfusion imaging was obtained.,PROCEDURE AND INTERPRETATION: ,The patient exercised for a total of 12 minutes on the standard Bruce protocol. The peak workload was 12.8 METS. The resting heart rate was 57 beats per minute and the peak heart rate was 123 beats per minute, which was 69% of the age-predicted maximum heart rate response. The blood pressure response was normal with a resting blood pressure of 130/100 and a peak blood pressure of 158/90. The test was stopped due to fatigue and leg pain. EKG at rest showed normal sinus rhythm. The peak stress EKG did not reveal any ischemic ST-T wave abnormalities. There was ventricular bigeminy seen during exercise, but no sustained tachycardia was seen. At peak, there was no chest pain noted. The test was stopped due to fatigue and left pain. At peak stress, the patient was injected with 30.3 mCi of Cardiolite technetium-99 m sestamibi and myocardial perfusion imaging was obtained, and was compared to resting myocardial perfusion imaging.,MYOCARDIAL PERFUSION IMAGING:,1. The overall quality of the scan was good.,2. There was no diagnostic abnormality on the rest and stress myocardial perfusion imaging.,3. The left ventricular cavity appeared normal in size.,4. Gated SPECT images revealed mild septal hypokinesis and mild apical hypokinesis. Overall left ventricular systolic function was low normal with calculated ejection fraction of 46% at rest.,CONCLUSIONS:,1. Good exercise tolerance.,2. Less than adequate cardiac stress. The patient was on beta-blocker therapy.,3. No EKG evidence of stress induced ischemia.,4. No chest pain with stress.,5. Mild ventricular bigeminy with exercise.,6. No diagnostic abnormality on the rest and stress myocardial perfusion imaging.,7. Gated SPECT images revealed septal and apical hypokinesis with overall low normal left ventricular systolic function with calculated ejection fraction of 46% at rest.

cardiovascular / pulmonary, myocardial perfusion imaging, bruce protocol, cardiolite, ekg, mets, mi, spect, st-t, bigeminy, blood pressure, chest pain, exercise tolerance, myocardial perfusion, normal sinus rhythm, peak workload, sestamibi, stents, stress, tachycardia, ventricular, ventricular cavity, stress myocardial perfusion, perfusion imaging, myocardial, perfusion, mci, hypokinesis, imaging,

Myocardial perfusion imaging - patient had previous abnormal stress test. Stress test with imaging for further classification of CAD and ischemia.

Cardiovascular / Pulmonary

Myocardial Perfusion Imaging - 2

CLINICAL HISTORY: , This is a 64-year-old male patient, who had a previous stress test, which was abnormal and hence has been referred for a stress test with imaging for further classification of coronary artery disease and ischemia.,PERTINENT MEDICATIONS:, Include Tylenol, Robitussin, Colace, Fosamax, multivitamins, hydrochlorothiazide, Protonix and flaxseed oil.,With the patient at rest 10.5 mCi of Cardiolite technetium-99 m sestamibi was injected and myocardial perfusion imaging was obtained.,PROCEDURE AND INTERPRETATION: , The patient exercised for a total of 4 minutes and 41 seconds on the standard Bruce protocol. The peak workload was 7 METs. The resting heart rate was 61 beats per minute and the peak heart rate was 173 beats per minute, which was 85% of the age-predicted maximum heart rate response. The blood pressure response was normal with the resting blood pressure 126/86, and the peak blood pressure of 134/90. EKG at rest showed normal sinus rhythm with a right-bundle branch block. The peak stress EKG was abnormal with 2 mm of ST segment depression in V3 to V6, which remained abnormal till about 6 to 8 minutes into recovery. There were occasional PVCs, but no sustained arrhythmia. The patient had an episode of supraventricular tachycardia at peak stress. The ischemic threshold was at a heart rate of 118 beats per minute and at 4.6 METs. At peak stress, the patient was injected with 30.3 mCi of Cardiolite technetium-99 m sestamibi and myocardial perfusion imaging was obtained, and was compared to resting images.,MYOCARDIAL PERFUSION IMAGING:,1. The overall quality of the scan was fair in view of increased abdominal uptake, increased bowel uptake seen.,2. There was a large area of moderate to reduced tracer concentration seen in the inferior wall and the inferior apex. This appeared to be partially reversible in the resting images.,3. The left ventricle appeared normal in size.,4. Gated SPECT images revealed normal wall motion and normal left ventricular systolic function with normal wall thickening. The calculated ejection fraction was 70% at rest.,CONCLUSIONS:,1. Average exercise tolerance.,2. Adequate cardiac stress.,3. Abnormal EKG response to stress, consistent with ischemia. No symptoms of chest pain at rest.,4. Myocardial perfusion imaging was abnormal with a large-sized, moderate intensity partially reversible inferior wall and inferior apical defect, consistent with inferior wall ischemia and inferior apical ischemia.,5. The patient had run of SVT at peak stress.,6. Gated SPECT images revealed normal wall motion and normal left ventricular systolic function.

cardiovascular / pulmonary, stress test, arrhythmia, baseline heart rate, bruce, chest pain, mets, protocol, peak heart rate, spect, st segment response, svt, aerobic capacity, blood pressure, exercise, heart rate, ischemia, ventricular systolic function, myocardial perfusion imaging, cardiolite technetium, inferior apical, myocardial perfusion, perfusion imaging, stress, myocardial, imaging, perfusion

Myocardial perfusion study at rest and stress, gated SPECT wall motion study at stress and calculation of ejection fraction.

Cardiovascular / Pulmonary

Myocardial Perfusion Imaging - 3

DIAGNOSIS: ,Shortness of breath. Fatigue and weakness. Hypertension. Hyperlipidemia.,INDICATION: , To evaluate for coronary artery disease.,

cardiovascular / pulmonary, myocardial perfusion imaging, spect wall motion study at stress, rest and stress, perfusion study at rest, calculation of ejection fraction, normal left ventricular wall, spect wall motion study, ventricular wall motion, myocardial perfusion study, perfusion imaging, blood pressure, nonspecific st, ventricular wall, gated spect, spect wall, motion study, stress test, heart rate, ejection fraction, myocardial perfusion, technetium, tetrofosmin, ischemia, ekg, imaging, spect, heart, ventricular, mci, resting, perfusion, stress, myocardial,

Multiple stent placements with Impella circulatory assist device.

Cardiovascular / Pulmonary

Multiple Stent Placements

PROCEDURE PERFORMED:,1. Left heart catheterization, left ventriculogram, aortogram, coronary angiogram.,2. PCI of the LAD and left main coronary artery with Impella assist device.,INDICATIONS FOR PROCEDURE: , Unstable angina and congestive heart failure with impaired LV function.,TECHNIQUE OF PROCEDURE: , After obtaining informed consent, the patient was brought to the cardiac catheterization suite in postabsorptive and nonsedated state. The right groin was prepped and draped in the usual sterile manner. Lidocaine 2% was used for infiltration anesthesia. Using modified Seldinger technique, a 7-French sheath was introduced into the right common femoral artery and a 6-French sheath was introduced into the right common femoral vein. Through the arterial sheath, angiography of the right common femoral artery was obtained. Thereafter, 6-French pigtail catheter was advanced to the level of the distal aorta where angiography of the distal aorta and the bifurcation of the right and left common iliac arteries was obtained. Thereafter, a 4-French sheath was introduced into the left common femoral artery using modified Seldinger technique. Thereafter, the pigtail catheter was advanced over an 0.035-inch J-wire into the left ventricle and LV-gram was performed in RAO view and after pullback, an aortogram was performed in the LAO view. Therefore, a 6-French JL4 and JR4 guiding catheters were used to engage the left and right coronary arteries respectively and multiple orthogonal views of the coronary arteries were obtained.,ANGIOGRAPHIC FINDINGS: ,1. LV-gram: LVEDP was 15 mmHg. LV ejection fraction 10% to 15% with global hypokinesis. Only anterior wall is contracting. There was no mitral regurgitation. There was no gradient across the aortic valve upon pullback, and on aortography, there was no evidence of aortic dissection or aortic regurgitation.,2. The right coronary artery is a dominant vessels with a mid 50% to 70% stenosis which was not treated. The left main coronary artery calcified vessel with disease.,2. The left anterior descending artery had an 80% to 90% mid-stenosis. First diagonal branch had a more than 90% stenosis.,3. The circumflex coronary artery had a patent stent.,INTERVENTION: , After reviewing the angiographic images, we elected to proceed with intervention of the left anterior descending artery. The 4-French sheath in the left common femoral artery was upsized to a 12-French Impella sheath through which an Amplatz wire and a 6-French multipurpose catheter were advanced into the left ventricle. The Amplatz wire was exchanged for an Impella 0.018-inch stiff wire. The multipurpose catheter was removed, and the Impella was advanced into the left ventricle and a performance level of 8 was achieved with a cardiac output of 2 to 2.5 l/min. Thereafter, a 7-French JL4 guiding catheter was used to engage the left coronary artery and an Asahi soft 0.014-inch wire was advanced into the left anterior descending artery and a second 0.014-inch Asahi soft wire was advanced into the diagonal branch. The diagonal branch was predilated with a 2.5 x 30-mm Sprinter balloon at nominal atmospheres and thereafter a 2.5 x 24 Endeavor stent was successfully deployed in the mid-LAD and a 3.0 x 15-mm Endeavor stent was deployed in the proximal LAD. The stent delivery balloon was used to post-dilate the overlapping segment. The LAD, the diagonal was rewires with an 0.014-inch Asahi soft wire and a 3.0 x 20-mm Maverick balloon was advanced into the LAD for post-dilatation and a 2.0 x 30-mm Sprinter balloon was advanced into the diagonal for kissing inflations which were performed at nominal atmospheres. At this point, it was noted that the left main had a retrograde dissection. A 3.5 x 18-mm Endeavor stent was successfully deployed in the left main coronary artery. The Asahi soft wire in the diagonal was removed and placed into the circumflex coronary artery. Kissing inflations of the LAD and the circumflex coronary artery were performed using 3.0 x 20 Maverick balloons x2 balloons, inflated at high atmospheres of 14.,RESULTS: , Lesion reduction in the LAD FROM 90% to 0% and TIMI 3 flow obtained. Lesion reduction in the diagonal from 90% to less than 60% and TIMI 3 flow obtained. Lesion reduction in the left maintained coronary artery from 50% to 0% and TIMI 3 flow obtained.,The patient tolerated the procedure well and the inflations well with no evidence of any hemodynamic instability. The Impella device was gradually decreased from performance level of 8 to performance level of 1 at which point it was removed into the aorta and it was turned off and the Impella was removed from the body and the 2 Perclose sutures were tightened. From the right common femoral artery, a 6-French IMA catheter was advanced and an 0.035-inch wire down into the left common femoral and superficial femoral artery, over which an 8 x 40 balloon was advanced and tamponade of the arteriotomy site of the left common femoral artery was performed from within the artery at 3 atmospheres for a total of 20 minutes. The right common femoral artery and vein sheaths were both sutured in place for further observation. Of note, the patient received Angiomax during the procedure and an ACT above 300 was maintained.,IMPRESSION:,1. Left ventricular dysfunction with ejection fraction of 10% to 15%.,2. High complex percutaneous coronary intervention of the left main coronary artery, left anterior descending artery, and diagonal with Impella circulatory support.,COMPLICATIONS: , None.,The patient tolerated the procedure well with no complications. The estimated blood loss was 200 ml. Estimated dye used was 200 ml of Visipaque. The patient remained hemodynamically stable with no hypotension and no hematomas in the groins.,PLAN: ,1. Aspirin, Plavix, statins, beta blockers, ACE inhibitors as tolerated.,2. Hydration.,3. The patient will be observed over night for any hemodynamic instability or ischemia. If she remains stable, the right common femoral artery and vein sheaths will be removed and manual pressure will be applied for hemostasis.

cardiovascular / pulmonary, impella circulatory assist device, impella assist device, unstable angina, congestive heart failure, heart catheterization, ventriculogram, aortogram, angiogram, ventricular dysfunction, pigtail catheter was advanced, femoral artery and vein, artery and vein, asahi soft wire, circumflex coronary artery, common femoral artery, modified seldinger technique, multiple stent placements, timi flow, multiple stent, impella circulatory, french sheath, femoral artery, endeavor stent, descending artery, coronary artery, common femoral, asahi soft, anterior descending, femoral, coronary, artery, impella, catheterization,

Resting Myoview perfusion scan and gated myocardial scan. Findings consistent with an inferior non-transmural scar

Cardiovascular / Pulmonary

Myoview Perfusion Scan

INDICATIONS:, Previously markedly abnormal dobutamine Myoview stress test and gated scan.,PROCEDURE DONE:, Resting Myoview perfusion scan and gated myocardial scan.,MYOCARDIAL PERFUSION IMAGING:, Resting myocardial perfusion SPECT imaging and gated scan were carried out with 32.6 mCi of Tc-99m Myoview. Rest study was done and compared to previous dobutamine Myoview stress test done on Month DD, YYYY. The lung heart ratio is 0.34. There appears to be a moderate size inferoapical perfusion defect of moderate degree. The gated myocardial scan revealed mild apical and distal inferoseptal hypokinesis with ejection fraction of 55%.,CONCLUSIONS:, Study done at rest only revealed findings consistent with an inferior non-transmural scar of moderate size and moderate degree. The left ventricular systolic function is markedly improved with much better regional wall motion of all left ventricular segments when compared to previous study done on Month DD, YYYY. We cannot assess the presence of any reversible perfusion defects because no stress imaging was performed.

cardiovascular / pulmonary, myoview perfusion scan, rest study, spect imaging, dobutamine myoview stress test, ejection fraction, gated myocardial scan, hypokinesis, ventricular systolic function, resting myoview perfusion scan, myoview stress test, resting myoview, myocardial perfusion, myoview perfusion, perfusion scan, myocardial scan, myocardial, myoview, perfusion

MRI: Right parietal metastatic adenocarcinoma (LUNG) metastasis.

Cardiovascular / Pulmonary

MRI of Lung - Adenocarcinoma

CC:, Found unresponsive.,HX: , 39 y/o RHF complained of a severe HA at 2AM 11/4/92. It was unclear whether she had been having HA prior to this. She took an unknown analgesic, then vomited, then lay down in bed with her husband. When her husband awoke at 8AM he found her unresponsive with "stiff straight arms" and a "strange breathing pattern." A Brain CT scan revealed a large intracranial mass. She was intubated and hyperventilated to ABG (7.43/36/398). Other local lab values included: WBC 9.8, RBC 3.74, Hgb 13.8, Hct 40.7, Cr 0.5, BUN 8.5, Glucose 187, Na 140, K 4.0, Cl 107. She was given Mannitol 1gm/kg IV load, DPH 20mg/kg IV load, and transferred by helicopter to UIHC.,PMH:, 1)Myasthenia Gravis for 15 years, s/p Thymectomy,MEDS:, Imuran, Prednisone, Mestinon, Mannitol, DPH, IV NS,FHX/SHX:, Married. Tobacco 10 pack-year; quit nearly 10 years ago. ETOH/Substance Abuse unknown.,EXAM:, 35.8F, 99BPM, BP117/72, Mechanically ventilated at a rate of 22RPM on !00%FiO2. Unresponsive to verbal stimulation. CN: Pupils 7mm/5mm and unresponsive to light (fixed). No spontaneous eye movement or blink to threat. No papilledema or intraocular hemorrhage noted. Trace corneal reflexes bilaterally. No gag reflex. No oculocephalic reflex. MOTOR/SENSORY: No spontaneous movement. On noxious stimulation (Deep nail bed pressure) she either extended both upper extremities (RUE>LUE), or withdrew the stimulated extremity (right > left). Gait/Station/Coordination no tested. Reflexes: 1+ on right and 2+ on left with bilateral Babinski signs.,HCT 11/4/92: Large heterogeneous mass in the right temporal-parietal region causing significant parenchymal distortion and leftward subfalcine effect . There is low parenchymal density within the white matter. A hyperdense ring lies peripherally and may represent hemorrhage or calcification. The mass demonstrates inhomogeneous enhancement with contrast.,COURSE:, Head of bed elevated to 30 degrees, Mannitol and DPH were continued. MRI of Brain demonstrated a large right parietal mass with necrotic appearing center and leftward shift of midline structures. She underwent surgical resection of the tumor. Pathological analysis was consistent with adenocarcinoma. GYN exam, CT Abdomen and Pelvis, Bone scan were unremarkable. CXR revealed an right upper lobe lung nodule. She did not undergo thoracic biopsy due to poor condition. She received 3000 cGy cranial XRT in ten fractions and following this was discharged to a rehabilitation center.,In March, 1993 the patient exhibited right ptosis, poor adduction and abduction OD, 4/4 strength in the upper extremities and 5-/5- strength in the lower extremities. She was ambulatory with an ataxic gait.,She was admitted on 7/12/93 for lower cervical and upper thoracic pain, paraparesis and T8 sensory level. MRI brainstem/spine on that day revealed decreased T1 signal in the C2, C3, C6 vertebral bodies, increased T2 signal in the anterior medulla, and tectum, and spinal cord (C7-T3). Following injection of Gadolinium there was diffuse leptomeningeal enhancement from C7-T7 These findings were felt consistent with metastatic disease including possible leptomeningeal spread. Neurosurgery and Radiation Oncology agreed that the patients symptoms could be due to either radiation injury and/or metastasis. The patient was treated with Decadron and analgesics and discharged to a hospice center (her choice). She died a few months later.

cardiovascular / pulmonary, mri, lung, metastatic adenocarcinoma, parietal, breathing pattern, cranial xrt, t1 signal, sensory level, iv load, adenocarcinoma, metastatic, leptomeningeal

Seizure, hypoglycemia, anemia, dyspnea, edema. colon cancer status post right hemicolectomy, hospital-acquired pneumonia, and congestive heart failure.

Cardiovascular / Pulmonary

Multiple Medical Problems - Discharge Summary

ADMISSION DIAGNOSES:,1. Seizure.,2. Hypoglycemia.,3. Anemia.,4. Hypotension.,5. Dyspnea.,6. Edema.,DISCHARGE DIAGNOSES:,1. Colon cancer, status post right hemicolectomy.,2. Anemia.,3. Hospital-acquired pneumonia.,4. Hypertension.,5. Congestive heart failure.,6. Seizure disorder.,PROCEDURES PERFORMED:,1. Colonoscopy.,2. Right hemicolectomy.,HOSPITAL COURSE: , The patient is a 59-year-old female with multiple medical problems including diabetes mellitus requiring insulin for 26 years, previous MI and coronary artery disease, history of seizure disorder, GERD, bipolar disorder, and anemia. She was admitted due to a seizure and myoclonic jerks as well as hypoglycemia and anemia. Regarding the seizure disorder, Neurology was consulted. Noncontrast CT of the head was negative. Neurology felt that the only necessary intervention at that time would be to increase her Lamictal to 150 mg in the morning and 100 mg in the evening with gradual increase of the dosage until she was on 200 mg b.i.d. Regarding the hypoglycemia, the patient has diabetic gastroparesis and was being fed on J-tube intermittent feedings throughout the night at the rate of 120 an hour. Her insulin pump had a basal rate of roughly three at night during the feedings. While in the hospital, the insulin pump rate was turned down to 1.5 and then subsequently decreased a few other times. She seemed to tolerate the insulin pump rate well throughout her hospital course. There were a few episodes of hypoglycemia as well as hyperglycemia, but the episode seem to be related to the patient's n.p.o. status and the changing rates of tube feedings throughout her hospital course.,At discharge, her endocrinologist was contacted. It was decided to change her insulin pump rate to 3 units per hour from midnight till 6 a.m., from 0.8 units per hour from 6 a.m. until 8 a.m., and then at 0.2 units per hour from 8 a.m. until 6 p.m. The insulin was to be NovoLog. Regarding the anemia, the gastroenterologists were consulted regarding her positive Hemoccult stools. A colonoscopy was performed, which found a mass at the right hepatic flexure. General Surgery was then consulted and a right hemicolectomy was performed on the patient. The patient tolerated the procedure well and tube feeds were slowly restarted following the procedure, and prior to discharge were back at her predischarge rates of 120 per hour. Regarding the cancer itself, it was found that 1 out of 53 nodes were positive for cancer. CT of the abdomen and pelvis revealed no metastasis, a CT of the chest revealed possible lung metastasis. Later in hospital course, the patient developed a septic-like picture likely secondary to hospital-acquired pneumonia. She was treated with Zosyn, Levaquin, and vancomycin, and tolerated the medications well. Her symptoms decreased and serial chest x-rays were followed, which showed some resolution of the illness. The patient was seen by the Infectious Disease specialist. The Infectious Disease specialist recommended vancomycin to cover MRSA bacteria, which was found at the J-tube site. At discharge, the patient was given three additional days of p.o. Levaquin 750 mg as well as three additional days of Bactrim DS every 12 hours. The Bactrim was used to cover the MRSA at the J-tube site. It was found that MRSA was sensitive to Bactrim. Throughout her hospital course, the patient continued to receive Coreg 12.5 mg daily and Lasix 40 mg twice a day for her congestive heart failure, which remains stable. She also received Lipitor for her high cholesterol. Her seizure disorder remained stable and she was discharged on a dose of 100 mg in the morning and 150 mg at night. The dosage increases can begin on an outpatient basis.,DISCHARGE INSTRUCTIONS/MEDICATIONS: , The patient was discharged to home. She was told to shy away from strenuous activity. Her discharge diet was to be her usual diet of isotonic fiber feeding through the J-tube at a rate of 120 per hour throughout the night. The discharge medications were as follows:,1. Coreg 12.5 mg p.o. b.i.d.,2. Lipitor 10 mg p.o. at bedtime.,3. Nitro-Dur patch 0.3 mg per hour one patch daily.,4. Phenergan syrup 6.25 mg p.o. q.4h. p.r.n.,5. Synthroid 0.175 mg p.o. daily.,6. Zyrtec 10 mg p.o. daily.,7. Lamictal 100 mg p.o. daily.,8. Lamictal 150 mg p.o. at bedtime.,9. Ferrous sulfate drops 325 mg, PEG tube b.i.d.,10. Nexium 40 mg p.o. at breakfast.,11. Neurontin 400 mg p.o. t.i.d.,12. Lasix 40 mg p.o. b.i.d.,13. Fentanyl 50 mcg patch transdermal q.72h.,14. Calcium and vitamin D combination, calcium carbonate 500 mg/vitamin D 200 units one tab p.o. t.i.d.,15. Bactrim DS 800mg/160 mg tablet one tablet q.12h. x3 days.,16. Levaquin 750 mg one tablet p.o. x3 days.,The medications listed above, one listed as p.o. are to be administered via the J-tube.,FOLLOWUP: ,The patient was instructed to see Dr. X in approximately five to seven days. She was given a lab sheet to have a CBC with diff as well as a CMP to be drawn prior to her appointment with Dr. X. She is instructed to follow up with Dr. Y if her condition changes regarding her colon cancer. She was instructed to follow up with Dr. Z, her oncologist, regarding the positive lymph nodes. We were unable to contact Dr. Z, but his telephone number was given to the patient and she was instructed to make a followup appointment. She was also instructed to follow up with her endocrinologist, Dr. A, regarding any insulin pump adjustments, which were necessary and she was also instructed to follow up with Dr. B, her gastroenterologist, regarding any issues with her J-tube.,CONDITION ON DISCHARGE: , Stable.

A female admitted with jaundice and a pancreatic mass who was noted to have a new murmur, bacteremia, and fever.

Cardiovascular / Pulmonary

Murmur & Bacteremia.

REASON FOR CONSULTATION: , New murmur with bacteremia.,HISTORY OF PRESENT ILLNESS:, The patient is an 84-year-old female admitted with jaundice and a pancreatic mass who was noted to have a new murmur, bacteremia, and fever. The patient states that apart from the fever, she was having no other symptoms and denies any previous cardiac history. She denies any orthopnea or paroxysmal nocturnal dyspnea. Denies any edema, chest pain, palpitations, or syncope. She has had TIAs in the past, but none recently.,PAST MEDICAL HISTORY:, Significant for diabetes, hypertension, and TIA.,MEDICATIONS: , Include:,1. Acidophilus supplement.,2. Cholestyramine.,3. Creon 20 three times daily.,4. Diovan 160 mg twice daily.,6. Lantus 10 daily.,7. Norvasc 5 mg daily.,8. NovoLog 70/30, 10 units at 12 noon daily.,9. Pamelor 15 mL every evening.,10. Vitamin D3 one tablet weekly.,ALLERGIES: , THE PATIENT IS ALLERGIC TO CODEINE, COREG, AND VANCOMYCIN.,FAMILY HISTORY: ,The patient's daughter apparently has history of a murmur, but no diagnosis of congenital heart disease. The patient's father died in his 80s of CHF.,SOCIAL HISTORY: , The patient denies ever having smoked, denies any significant alcohol use, and lives with her daughter in Pasadena.,REVIEW OF SYSTEMS: , The patient has had fever and chills. She has also had some jaundice. Denies any nausea or vomiting. Denies any chest pain or abdominal pain. Denies orthopnea, paroxysmal nocturnal dyspnea or edema. She has had TIAs in the past, but denies any recent neurological symptoms such as motor weakness or focal sensory deficits. Denies melena or hematochezia. All other systems were reviewed and were found to be negative.,PHYSICAL EXAMINATION,GENERAL: An elderly Caucasian female, awake and alert, and in no distress.,VITAL SIGNS: Temperature is 98.8, heart rate 96, sinus, blood pressure 138/55, respiratory rate 20, and oxygen saturation 92%.,HEAD AND NECK: Her head is atraumatic. She is normocephalic. Her neck is supple. There is no JVD. No palpable adenopathy or thyromegaly. There is some icterus of the sclerae bilaterally. Oral mucosa is moist.,CHEST: Symmetrical expansion with normal percussion note. There are no inspiratory crackles or expiratory wheeze.,CARDIAC: Heart sounds S1 and S2 are regular. There is a 2/6 systolic murmur heard through the precordium. There is no gallop or rub. There is no palpable thrill or retrosternal lift.,ABDOMEN: Soft, nondistended, and nontender with normal bowel sounds. No audible bruits.,EXTREMITIES: No pitting edema, no clubbing, no cyanosis, and peripheral pulses are 2+.,NEUROLOGIC: She exhibits no focal motor or sensory findings.,LABORATORY DATA: , The patient's sodium was 133, potassium 2.8, chloride 99, bicarbonate 31, glucose 75, BUN 12, creatinine 0.8, calcium 8.6, total bilirubin 3.2, AST 63, and ALT 43. White count 5.4, hemoglobin 9.1, hematocrit 26.6, and platelet count 128,000. Lipase less than 10.,DIAGNOSTIC IMAGING: , The patient had a CT scan of the abdomen that demonstrated a pancreatic mass with biliary obstruction. Previous biliary stent was present.,EKG shows normal sinus rhythm. There are no acute ST-T changes.,ASSESSMENT: , This is an 84-year-old female with newly found murmur. No previous history of heart disease. This murmur has occurred in the setting of fever and bacteremia. The patient also has a pancreatic mass with jaundice, history of hypertension, and now has hyponatremia and hypokalemia.,PLAN: ,The patient should undergo an echocardiogram to assess for the possibility of endocarditis, which may be contributing to her symptoms. Blood pressure control should be maintained with Diovan and Norvasc. Potassium should be replaced, and hyponatremia should be on proactive.

Loculated left effusion, multilobar pneumonia. Patient had a diagnosis of multilobar pneumonia along with arrhythmia and heart failure as well as renal insufficiency.

Cardiovascular / Pulmonary

Multilobar Pneumonia

REASON FOR CONSULTATION: , Loculated left effusion, multilobar pneumonia.

cardiovascular / pulmonary, neck bruits, nasal cannula, rhythm, pneumonia, chest tube, fluid collection, pleural effusion, multilobar pneumonia, pleural, loculations, multilobar,

Mitral valve repair using a quadrangular resection of the P2 segment of the posterior leaflet. Mitral valve posterior annuloplasty using a Cosgrove Galloway Medtronic fuser band. Posterior leaflet abscess resection.

Cardiovascular / Pulmonary

Mitral Valve Repair & Annuloplasty

OPERATIONS,1. Mitral valve repair using a quadrangular resection of the P2 segment of the posterior leaflet.,2. Mitral valve posterior annuloplasty using a Cosgrove Galloway Medtronic fuser band.,3. Posterior leaflet abscess resection.,ANESTHESIA: ,General endotracheal anesthesia,TIMES: ,Aortic cross-clamp time was ** minutes. Cardiopulmonary bypass time total was ** minutes.,PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered. Next, the patient's chest and legs were prepped and draped in standard surgical fashion. A #10-blade scalpel was used to make a midline median sternotomy incision. Dissection was carried down to the level of the sternum using Bovie electrocautery. The sternum was opened with a sternal saw, and full-dose heparinization was given. Next, the chest retractor was positioned. The pericardium was opened with Bovie electrocautery and pericardial stay sutures were positioned. We then prepared to place the patient on cardiopulmonary bypass. A 2-0 Ethibond double pursestring was placed in the ascending aorta. Through this was passed our aortic cannula and connected to the arterial side of the cardiopulmonary bypass machine. Next, double cannulation with venous cannulas was instituted. A 3-0 Prolene pursestring was placed in the right atrial appendage. Through this was passed our SEC cannula. This was connected to the venous portion of the cardiopulmonary bypass machine in a Y-shaped circuit. Next, a 3-0 Prolene pursestring was placed in the lower border of the right atrium. Through this was passed our inferior vena cava cannula. This was likewise connected to the Y connection of our venous cannula portion. We then used a 4-0 U-stitch in the right atrium for our retrograde cardioplegia catheter, which was inserted. Cardiopulmonary bypass was instituted. Metzenbaum scissors were used to dissect out the SVC and IVC, which were subsequently encircled with umbilical tape. Sondergaard's groove was taken down. Next, an antegrade cardioplegia needle and associated sump were placed in the ascending aorta. This was connected appropriately as was the retrograde cardioplegia catheter. Next, the aorta was cross-clamped, and antegrade and retrograde cardioplegia was infused so as to arrest the heart in diastole. Next a #15-blade scalpel was used to open the left atrium. The left atrium was decompressed with pump sucker. Next, our self-retaining retractor was positioned so as to bring the mitral valve up into view. Of note was the fact that the mitral valve P2 segment of the posterior leaflet had an abscess associated with it. The borders of the P2 segment abscess were defined by using a right angle to define the chordae which were encircled with a 4-0 silk. After doing so, the P2 segment of the posterior leaflet was excised with a #11-blade scalpel. Given the laxity of the posterior leaflet, it was decided to reconstruct it with a 2-0 Ethibond pledgeted suture. This was done so as to reconstruct the posterior annular portion. Prior to doing so, care was taken to remove any debris and abscess-type material. The pledgeted stitch was lowered into place and tied. Next, the more anterior portion of the P2 segment was reconstructed by running a 4-0 Prolene stitch so as to reconstruct it. This was done without difficulty. The apposition of the anterior and posterior leaflet was confirmed by infusing solution into the left ventricle. There was noted to be a small amount of central regurgitation. It was felt that this would be corrected with our annuloplasty portion of the procedure. Next, 2-0 non-pledgeted Ethibond sutures were placed in the posterior portion of the annulus from trigone to trigone in interrupted fashion. Care was taken to go from trigone to trigone. Prior to placing these sutures, the annulus was sized and noted to be a *** size for the Cosgrove-Galloway suture band ring from Medtronic. After, as mentioned, we placed our interrupted sutures in the annulus, and they were passed through the CG suture band. The suture band was lowered into position and tied in place. We then tested our repair and noted that there was very mild regurgitation. We subsequently removed our self-retaining retractor. We closed our left atriotomy using 4-0 Prolene in a running fashion. This was done without difficulty. We de-aired the heart. We then gave another round of antegrade and retrograde cardioplegia in warm fashion. The aortic cross-clamp was removed, and the heart gradually resumed electromechanical activity. We then removed our retrograde cardioplegia catheter from the coronary sinus and buttressed this site with a 5-0 Prolene. We placed 2 ventricular and 2 atrial pacing leads which were brought out through the skin. The patient was gradually weaned off cardiopulmonary bypass and our venous cannulas were removed. We then gave full-dose protamine; and after noting that there was no evidence of a protamine reaction, we removed our aortic cannula. This site was buttressed with a 4-0 Prolene on an SH needle. The patient tolerated the procedure well. We placed a mediastinal #32-French chest tube as well as a right chest Blake drain. The mediastinum was inspected for any signs of bleeding. There were none. We closed the sternum with #7 sternal wires in interrupted figure-of-eight fashion. The fascia was closed with a #1 Vicryl followed by a 2-0 Vicryl, followed by 3-0 Vicryl in a running subcuticular fashion. The instrument and sponge count was correct at the end of the case. The patient tolerated the procedure well and was transferred to the intensive care unit in good condition.

cardiovascular / pulmonary, mitral valve repair, mitral valve, abscess resection, leaflet abscess, cosgrove galloway medtronic, bovie electrocautery, cannulation, bypass, annuloplasty, cardioplegia, mitral,

Suspension microlaryngoscopy, rigid bronchoscopy, dilation of tracheal stenosis.

Cardiovascular / Pulmonary

Microlaryngoscopy

PREOPERATIVE DIAGNOSIS:, Airway obstruction secondary to laryngeal subglottic stenosis.,POSTOPERATIVE DIAGNOSIS: ,Airway obstruction secondary to laryngeal subglottic stenosis and tracheal stenosis.,OPERATION PERFORMED: , Suspension microlaryngoscopy, rigid bronchoscopy, dilation of tracheal stenosis.,INDICATIONS FOR SURGERY: ,The patient is a 56-year-old white female with a history of relapsing polychondritis, which resulted in saddle nose deformity in glottic and subglottic stenosis for which she has undergone number of procedures in the past to the upper airway. She currently is trach dependent for her airway because of glottic and subglottic stenosis, but she is having no significant problems breathing and talking around her trach tube and came for further evaluation. Endoscopic reevaluation of her tube and nature of the proposed procedure done. Risk and complications of bleeding, infection, alteration of with speech or swallowing, failure to improve her airway, and loss of voice. Cardiorespiratory anesthetic results were discussed in length. The patient states she understood and wished to proceed.,DESCRIPTION OF OPERATION:, The patient was taken to the operating room and placed in the supine position. Under adequate general endotracheal anesthesia, the patient's #5 metal tracheostomy tube was removed and a #5 laser-safe endotracheal tube was inserted. The patient was then prepared for endoscopy. The Kantor laryngoscope was then inserted. Oral cavity, hypopharynx, larynx, and nasal cavity showed good dentition with good tongue, buccal cavity, and mucosa without lesions. Larynx was then ***** short epiglottis. Larynx was suspended with significant scarring beginning in the supraglottic area with loss of laryngeal contour beginning in the supraglottis with extensive scar tissue at the level of the false cord obliteration of ventricles and true cords. This appeared to be stable, and airway was patent at the supraglottic and glottic level with some narrowing at the subglottic level with mild-to-moderate subglottic stenosis, otherwise this appeared to be stable. However, distally, the level of the trach site examined with the microscope and 0 and 30-degree telescopes. The patient noted to have marked narrowing with dense scarring posterolaterally on the left securing good visualization of the trach tube. The laryngoscope was removed, and a 5 x 30 pediatric rigid bronchoscope was then passed. The LP contact tip laser was utilized to vaporize the scar tissue and release the scar banding following which the scope was passed and further dilation carried out. Mid and distal trachea were widely patent. Trachea and mainstem bronchi were patent without obvious disease. The patient did not appear to have any relapsing polychondritis with progressive scar tissue at the level of the trach site and the posterior trachea wall was significant. This was further dilated and following which was removed and a new #5 metal tracheostomy tube inserted. The patient tolerated the procedure well without complications and was taken to recovery room in satisfactory condition.

cardiovascular / pulmonary, airway obstruction, oral cavity, bronchoscopy, buccal cavity, hypopharynx, laryngeal, larynx, microlaryngoscopy, nasal cavity, polychondritis, subglottic, tracheal stenosis, tracheostomy tube, scar tissue, subglottic stenosis, tracheal, airway, cavity, tube, scarring, stenosis,

Right pleural effusion and suspected malignant mesothelioma.

Cardiovascular / Pulmonary

Mesothelioma - Pleural Biopsy

PREOPERATIVE DIAGNOSIS: , Right pleural effusion and suspected malignant mesothelioma.,POSTOPERATIVE DIAGNOSIS:, Right pleural effusion, suspected malignant mesothelioma.,PROCEDURE: , Right VATS pleurodesis and pleural biopsy.,ANESTHESIA:, General double-lumen endotracheal.,DESCRIPTION OF FINDINGS: , Right pleural effusion, firm nodules, diffuse scattered throughout the right pleura and diaphragmatic surface.,SPECIMEN: , Pleural biopsies for pathology and microbiology.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid 1.2 L and 1.9 L of pleural effusion drained.,INDICATIONS: , Briefly, this is a 66-year-old gentleman who has been transferred from an outside hospital after a pleural effusion had been drained and biopsies taken from the right chest that were thought to be consistent with mesothelioma. Upon transfer, he had a right pleural effusion demonstrated on x-ray as well as some shortness of breath and dyspnea on exertion. The risks, benefits, and alternatives to right VATS pleurodesis and pleural biopsy were discussed with the patient and his family and they wished to proceed.,PROCEDURE IN DETAIL: ,After informed consent was obtained, the patient was brought to the operating room and placed in supine position. A double-lumen endotracheal tube was placed. SCDs were also placed and he was given preoperative Kefzol. The patient was then brought into the right side up, left decubitus position, and the area was prepped and draped in the usual fashion. A needle was inserted in the axillary line to determine position of the effusion. At this time, a 10-mm port was placed using the knife and Bovie cautery. The effusion was drained by placing a sucker into this port site. Upon feeling the surface of the pleura, there were multiple firm nodules. An additional anterior port was then placed in similar fashion. The effusion was then drained with a sucker. Multiple pleural biopsies were taken with the biopsy device in all areas of the pleura. Of note, feeling the diaphragmatic surface, it appeared that it was quite nodular, but these nodules felt as though they were on the other side of the diaphragm and not on the pleural surface of the diaphragm concerning for a possibly metastatic disease. This will be worked up with further imaging study later in his hospitalization. After the effusion had been drained, 2 cans of talc pleurodesis aerosol were used to cover the lung and pleural surface with talc. The lungs were then inflated and noted to inflate well. A 32 curved chest tube chest tube was placed and secured with nylon. The other port site was closed at the level of the fascia with 2-0 Vicryl and then 4-0 Monocryl for the skin. The patient was then brought in the supine position and extubated and brought to recovery room in stable condition.,Dr. X was present for the entire procedure which was right VATS pleurodesis and pleural biopsies.,The counts were correct x2 at the end of the case.

cardiovascular / pulmonary, double-lumen, endotracheal, pleural surface, chest tube, pleural biopsy, malignant mesothelioma, vats pleurodesis, pleural biopsies, pleural effusion, pleural, vats, pleurodesis, mesothelioma,

Mesothelioma versus primary lung carcinoma, Chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, malignant pleural effusion, status post surgery as stated above, and anemia of chronic disease.

Cardiovascular / Pulmonary

Mesothelioma - Consult

REASON FOR CONSULTATION: , Mesothelioma.,HISTORY OF PRESENT ILLNESS: , The patient is a 73-year-old pleasant Caucasian male who is known to me from his previous hospitalization. He has also been seen by me in the clinic in the last few weeks. He was admitted on January 18, 2008, with recurrent malignant pleural effusion. On the same day, he underwent VATS and thoracoscopic drainage of the pleural effusion with right pleural nodule biopsy, lysis of adhesions, and directed talc insufflation by Dr. X. He was found to have 2.5L of bloody pleural effusions, some loculated pleural effusion, adhesions, and carcinomatosis in the parenchyma. His hospital course here has been significant for dyspnea, requiring ICU stay. He also had a chest tube, which was taken out few days ago. He has also had paroxysmal atrial fibrillation, for which he has been on amiodarone by cardiologist. The biopsy from the pleural nodule done on the right on January 18, 2008, shows malignant epithelioid neoplasm consistent with mesothelioma. Immunohistochemical staining showed tumor cells positive for calretinin and focally positive for D2-40, MOC-31. Tumor cells are negative for CDX-2, and monoclonal CEA.,The patient at this time reports that overall he has been feeling better with decrease in shortness of breath and cough over the last few days. He does have edema in his lower extremities. He is currently on 4L of oxygen. He denies any nausea, vomiting, abdominal pain, recent change in bowel habit, melena, or hematochezia. No neurological or musculoskeletal signs or symptoms. He reports that he is able to ambulate to the bathroom, but gets short of breath on exertion. He denies any other complaints.,PAST MEDICAL HISTORY:, Left ventricular systolic dysfunction as per the previous echocardiogram done in December 2007, history of pneumonia in December 2007, admitted to XYZ Hospital. History of recurrent pleural effusions, status post pleurodesis and locally advanced non-small cell lung cancer as per the biopsy that was done in XYZ Hospital.,ALLERGIES:, No known drug allergies.,CURRENT MEDICATIONS: ,In the hospital are amiodarone, diltiazem, enoxaparin, furosemide, methylprednisolone, pantoprazole, Zosyn, p.r.n. acetaminophen, and hydrocodone.,SOCIAL HISTORY: , The patient is married and lives with his spouse. He has history of tobacco smoking and also reports history of alcohol abuse. No history of illicit drug abuse.,FAMILY HISTORY: ,Significant for history of ?cancer? in the mother and history of coronary artery disease in the father.,REVIEW OF SYSTEMS: , As stated above. He denies any obvious asbestos exposure, as far as he can remember.,PHYSICAL EXAMINATION,GENERAL: He is awake, alert, in no acute distress. He is currently on 4L of oxygen by nasal cannula.,VITAL SIGNS: Blood pressure 97/65 mmHg, respiration is 20 per minute, pulse is 72 per minute, and temperature 98.3 degrees Fahrenheit.,HEENT: No icterus or sinus tenderness. Oral mucosa is moist.,NECK: Supple. No lymphadenopathy.,LUNGS: Clear to auscultation except few diffuse wheezing present bilaterally.,CARDIOVASCULAR: S1 and S2 normal.,ABDOMEN: Soft, nondistended, and nontender. No hepatosplenomegaly. Bowel sounds are present in all four quadrants.,EXTREMITIES: Bilateral pedal edema is present in both the extremities. No signs of DVT.,NEUROLOGICAL: Grossly nonfocal.,INVESTIGATION:, Labs done on January 28, 2008, showed BUN of 23 and creatinine of 0.9. Liver enzymes checked on January 17, 2008, were unremarkable. CBC done on January 26, 2008, showed WBC of 19.8, hemoglobin of 10.7, hematocrit of 30.8, and platelet count of 515,000. Chest x-ray from yesterday shows right-sided Port-A-Cath, diffuse right lung parenchymal and pleural infiltration without change, mild pulmonary vascular congestion.,ASSESSMENT,1. Mesothelioma versus primary lung carcinoma, two separate reports as for the two separate biopsies done several weeks apart.,2. Chronic obstructive pulmonary disease.,3. Paroxysmal atrial fibrillation.,4. Malignant pleural effusion, status post surgery as stated above.,5. Anemia of chronic disease.,RECOMMENDATIONS,1. Compare the slides from the previous biopsy done in December at XYZ Hospital with recurrent pleural nodule biopsy slides. I have discussed regarding this with Dr. Y in Pathology here at Methodist XYZ Hospital. I will try to obtain the slides for comparison from XYZ Hospital for comparison and immunohistochemical staining.,2. I will also discuss with Dr. X and also with intervention radiologist at XYZ Hospital regarding the exact sites of the two biopsies.,3. Once the results of the above are available, I will make further recommendations regarding treatment. The patient has significantly decreased performance status with dyspnea on exertion and is being planned for transfer to Triumph Hospital for rehab, which I agree with.,4. Continue present care.,Discussed regarding the above in great details with the patient and his wife and daughter and answered the questions to their satisfaction. They clearly understand the above. They also understand his very poor performance status at this time, and the risks and benefits of delaying chemotherapy due to this.

Posterior mediastinal mass with possible neural foraminal involvement (benign nerve sheath tumor by frozen section). Left thoracotomy with resection of posterior mediastinal mass.

Cardiovascular / Pulmonary

Mediastinal Mass Resection

PREOPERATIVE DIAGNOSIS:, Posterior mediastinal mass with possible neural foraminal involvement.,POSTOPERATIVE DIAGNOSIS: , Posterior mediastinal mass with possible neural foraminal involvement (benign nerve sheath tumor by frozen section).,OPERATION PERFORMED:, Left thoracotomy with resection of posterior mediastinal mass.,INDICATIONS FOR PROCEDURE: ,The patient is a 23-year-old woman who recently presented with a posterior mediastinal mass and on CT and MRI there were some evidence of potential widening of one of the neural foramina. For this reason, Dr. X and I agreed to operate on this patient together. Please note that two surgeons were required for this case due to the complexity of it. The indications and risks of the procedure were explained and the patient gave her informed consent.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating suite and placed in the supine position. General endotracheal anesthesia was given with a double lumen tube. The patient was positioned for a left thoracotomy. All pressure points were carefully padded. The patient was prepped and draped in usual sterile fashion. A muscle sparing incision was created several centimeters anterior to the tip of the scapula. The serratus and latissimus muscles were retracted. The intercostal space was opened. We then created a thoracoscopy port inferiorly through which we placed a camera for lighting and for visualization. Through our small anterior thoracotomy and with the video-assisted scope placed inferiorly we had good visualization of the posterior mediastinum mass. This was in the upper portion of the mediastinum just posterior to the subclavian artery and aorta. The lung was deflated and allowed to retract anteriorly. With a combination of blunt and sharp dissection and with attention paid to hemostasis, we were able to completely resect the posterior mediastinal mass. We began by opening the tumor and taking a very wide large biopsy. This was sent for frozen section, which revealed a benign nerve sheath tumor. Then, using the occluder device Dr. X was able to _____ the inferior portions of the mass. This left the external surface of the mass much more malleable and easier to retract. Using a bipolar cautery and endoscopic scissors we were then able to completely resect it. Once the tumor was resected, it was then sent for permanent sections. The entire hemithorax was copiously irrigated and hemostasis was complete. In order to prevent any lymph leak, we used 2 cc of Evicel and sprayed this directly on to the raw surface of the pleural space. A single chest tube was inserted through our thoracoscopy port and tunneled up one interspace. The wounds were then closed in multiple layers. A #2 Vicryl was used to approximate the ribs. The muscles of the chest wall were allowed to return to their normal anatomic position. A 19 Blake was placed in the subcutaneous tissues. Subcutaneous tissues and skin were closed with running absorbable sutures. The patient was then rolled in the supine position where she was awakened from general endotracheal anesthesia and taken to the recovery room in stable condition.

cardiovascular / pulmonary, posterior mediastinal mass, neural foraminal, nerve sheath tumor, frozen section, thoracotomy, mediastinal mass, foraminal, neural, sheath, mediastinal,

Myoview nuclear stress study. Angina, coronary artery disease. Large fixed defect, inferior and apical wall, related to old myocardial infarction.

Cardiovascular / Pulmonary

Mayoview - 1

MYOVIEW NUCLEAR STRESS STUDY,REASON FOR THE TEST:, Angina, coronary artery disease.,FINDINGS: , The patient exercised according to the Lexiscan nuclear stress study, received a total of 0.4 mg of Lexiscan. At peak hyperemic effect, 25.8 mCi of Myoview injected for the stress imaging and earlier 8.1 mCi of Myoview injected for the resting and the usual SPECT and gated SPECT protocol was followed in the rest-stress sequence.,The data analyzed using Cedars-Sinai software.,The resting heart rate was 49 with the resting blood pressure of 149/86. Maximum heart rate achieved was 69 with a maximum blood pressure achieved of 172/76.,EKG at rest showed to be abnormal with sinus rhythm, left atrial enlargement, and inverted T-wave in 1, 2, and aVL as well as from V4 to V6 with LVH. Maximal stress test EKG showed no change from baseline.,IMPRESSION: ,Maximal Lexiscan stress test with abnormal EKG at baseline maximal stress test, please refer to the Myoview interpretation.,MYOVIEW INTERPRETATIONS,FINDINGS: , The left ventricle appears to be dilated on both stress and rest with no significant change between stress and rest with left ventricular end-diastolic volume of 227, end-systolic volume of 154 with moderately to severely reduced LV function with akinesis of the inferior and inferoseptal wall. EF was calculated at 32%, estimated 35% to 40%.,Cardiac perfusion reviewed, showed a large area of moderate-to-severe intensity in the inferior wall and small-to-medium area of severe intensity at the apex and inferoapical wall. Both defects showed no change on the resting indicative of a fixed defect in the inferior and inferoapical wall consistent with old inferior inferoapical MI. No reversible defects indicative of myocardium at risk. The lateral walls as well as the septum and most of the anterior wall showed no reversibility and near-normal perfusion.,IMPRESSION:,1. Large fixed defect, inferior and apical wall, related to old myocardial infarction.,2. No reversible ischemia identified.,3. Moderately reduced left ventricular function with ejection fraction of about 35% consistent with ischemic cardiomyopathy.

cardiovascular / pulmonary, myoview, myoview interpretations, spect, gated spect protocol, myoview nuclear stress study, nuclear stress study, stress study, stress test, stress, lexiscan, ekg, inferoapical, angina, wall, resting,

Left metastasectomy of metastatic renal cell carcinoma with additional mediastinal lymph node dissection and additional fiberoptic bronchoscopy.

Cardiovascular / Pulmonary

Metastasectomy & Bronchoscopy

PREOPERATIVE DIAGNOSIS: ,Metastatic renal cell carcinoma.,POSTOPERATIVE DIAGNOSIS:, Metastatic renal cell carcinoma.,PROCEDURE PERFORMED:, Left metastasectomy of metastatic renal cell carcinoma with additional mediastinal lymph node dissection and additional fiberoptic bronchoscopy used to confirm adequate placement of the double-lumen endotracheal tube with a tube thoracostomy, which was used to drain the left chest after the procedure.,ANESTHESIA:, General endotracheal anesthesia with double-lumen endotracheal tube.,FINDINGS:, Multiple pleural surface seeding, many sub-millimeter suspicious looking lesions.,DISPOSITION OF SPECIMENS:,To Pathology for permanent analysis as well as tissue banking. The lesions sent for pathologic analysis were the following,,1. Level 8 lymph node.,2. Level 9 lymph node.,3. Wedge, left upper lobe apex, which was also sent to the tissue bank and possible multiple lesions within this wedge.,4. Wedge, left upper lobe posterior.,5. Wedge, left upper lobe anterior.,6. Wedge, left lower lobe superior segment.,7. Wedge, left lower lobe diaphragmatic surface, anterolateral.,8. Wedge, left lower lobe, anterolateral.,9. Wedge, left lower lobe lateral adjacent to fissure.,10. Wedge, left upper lobe, apex anterior.,11. Lymph node package, additional level 8 lymph node.,ESTIMATED BLOOD LOSS:, Less than 100 mL.,CONDITION OF THE PATIENT AFTER SURGERY: , Stable.,HISTORY OF PROCEDURE: , The patient was given preoperative informed consent for the procedure as well as for the clinical trial he was enrolled into. The patient agreed based on the risks and the benefits of the procedure, which were presented to him and was taken to the operating room. A correct time out procedure was performed. The patient was placed into the supine position. He was given general anesthesia, was endotracheally intubated without incident with a double-lumen endotracheal tube. Fiberoptic bronchoscopy was used to perform confirmation of adequate placement of the double-lumen tube. Following this, the decision was made to proceed with the surgery. The patient was rolled into the right lateral decubitus position with the left side up. All pressure points were padded. The patient had a sterile DuraPrep preparation to the left chest. A sterile drape around that was applied. Also, the patient had Marcaine infused into the incision area. Following this, the patient had a posterolateral thoracotomy incision, which was a muscle-sparing incision with a posterior approach just over the ausculatory triangle. The incision was approximately 10 cm in size. This was created with a 10-blade scalpel. Bovie electrocautery was used to dissect the subcutaneous tissues. The auscultatory triangle was opened. The posterior aspect of the latissimus muscle was divided from the adjacent tissue and retracted anteriorly. The muscle was not divided. After the latissimus muscle was retracted anteriorly, the ribs were counted, and the sixth rib was identified. The superior surface of the sixth rib was incised with Bovie electrocautery and the sixth rib was divided with rib shears. Following this, the patient had the entire intercostal muscle separated from the superior aspect of the sixth rib on the left as far as the Bovie would reach. The left lung was allowed to collapse and meticulous inspection of the left lung identified the lesions, which were taken out with stapled wedge resections via a TA30 green load stapler for all of the wedges. The patient tolerated the procedure well without any complications. The largest lesion was the left upper lobe apex lesion, which was possibly multiple lesions, which was taken in one large wedge segment, and this was also adjacent to another area of the wedges. The patient had multiple pleural abnormalities, which were identified on the surface of the lung. These were small white spotty looking lesions and were not confirmed to be tumor implants, but were suspicious to be multiple areas of tumor. Based on this, the wedges of the tumors that were easily palpable were excised with complete excision of all palpable lesions. Following this, the patient had a 32-French chest tube placed in the anteroapical position. A 19-French Blake was placed in the posterior apical position. The patient had the intercostal space reapproximated with #2-0 Vicryl suture, and the lung was allowed to be re-expanded under direct visualization. Following this, the chest tubes were placed to Pleur-evac suction and the auscultatory triangle was closed with 2-0 Vicryl sutures. The deeper tissue was closed with 3-0 Vicryl suture, and the skin was closed with running 4-0 Monocryl suture in a subcuticular fashion. The patient tolerated the procedure well and had no complications.

Resting Myoview and adenosine Myoview SPECT

Cardiovascular / Pulmonary

Mayoview

PROCEDURE DONE: ,Resting Myoview and adenosine Myoview SPECT.,INDICATIONS:, Chest pain.,PROCEDURE:, 13.3 mCi of Tc-99m tetrofosmin was injected and resting Myoview SPECT was obtained. Pharmacologic stress testing was done using adenosine infusion. Patient received 38 mg of adenosine infused at 140 mcg/kg/minute over a period of four minutes. Two minutes during adenosine infusion, 31.6 mCi of Tc-99m tetrofosmin was injected. Resting heart rate was 90 beats per minute. Resting blood pressure was 130/70. Peak heart rate obtained during adenosine infusion was 102 beats per minute. Blood pressure obtained during adenosine infusion was 112/70. During adenosine infusion, patient experienced dizziness and shortness of breath. No significant ST segment, T wave changes, or arrhythmias were seen.,Resting Myoview and adenosine Myoview SPECT showed uniform uptake of isotope throughout myocardium without any perfusion defect. Gated dynamic imaging showed normal wall motion and normal systolic thickening throughout left ventricular myocardium. Left ventricular ejection fraction obtained during adenosine Myoview SPECT was 77%. Lung heart ratio was 0.40. TID ratio was 0.88.,IMPRESSION:, Normal adenosine Myoview myocardial perfusion SPECT. Normal left ventricular regional and global function with left ventricular ejection fraction of 77%.

cardiovascular / pulmonary, myoview, gated dynamic imaging, myoview spect, resting myoview, spect, tc-99m, adenosine myoview, adenosine infusion, ejection fraction, myocardium, systolic thickening, tetrofosmin, adenosine myoview spect, adenosine,

Patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI. The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion.

Cardiovascular / Pulmonary

Lung Cancer & MI - Hospice Cosult

REASON FOR CONSULT: , I was asked to see this patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI.,HISTORY OF PRESENT ILLNESS: , The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion. Her daughter who accompanies her is very attentive whom I had met previously during drainage of a malignant hemorrhagic pericardial effusion last month. The patient has been feeling well for the last several weeks, per the daughter, but today per the personal aide, became agitated and uncomfortable at about 2:30 p.m. At about 7 p.m., the patient began vomiting, was noted to be short of breath by her daughter with garbled speech, arms flopping, and irregular head movements. Her daughter called 911 and her symptoms seemed to improve. Then, she began vomiting. When the patient's daughter asked her if she had chest pain, the patient said yes.,She came to the emergency room, an EKG showed inferior ST-elevation MI. I was called immediately and knowing her history, especially, her hospice status with recent hemorrhagic pericardial effusion, I felt thrombolytic was contraindicated and she would not be a candidate for aggressive interventional therapy with PCI/CABG. She was begun after discussion with the oncologist, on heparin drip and has received morphine, nitro, and beta-blocker, and currently states that she is pain free. Repeat EKG shows normalization of her ST elevation in the inferior leads as well as normalization of prior reciprocal changes.,PAST MEDICAL HISTORY: , Significant for metastatic non-small-cell lung cancer. In early-to-mid December, she had an admission and was found to have a malignant pericardial effusion with tamponade requiring urgent drainage. We did repeat an echo several weeks later and that did not show any recurrence of the pericardial effusion. She is on hospice from the medical history, atrial fibrillation, hypertension, history of multiple CVA.,MEDICATIONS: , Medications as an outpatient:,1. Amiodarone 200 mg once a day.,2. Roxanol concentrate 5 mg three hours p.r.n. pain.,ALLERGIES: ,CODEINE. NO SHRIMP, SEAFOOD, OR DYE ALLERGY.,FAMILY HISTORY: , Negative for cardiac disease.,SOCIAL HISTORY: , She does not smoke cigarettes. She uses alcohol. No use of illicit drugs. She is divorced and lives with her daughter. She is a retired medical librarian from Florida.,REVIEW OF SYSTEMS: ,Unable to be obtained due to the patient's aphasia.,PHYSICAL EXAMINATION: , Height 5 feet 3, weight of 106 pounds, temperature 97.1 degrees, blood pressure ranges from 138/82 to 111/87, pulse 61, respiratory rate 22. O2 saturation 100%. On general exam, she is an elderly woman with now marked aphasia, which per her daughter waxes and wanes, was more pronounced and she nods her head up and down when she says the word, no, and conversely, she nods her head side-to-side when she uses the word yes with some discordance in her head gestures with vocalization. HEENT shows the cranium is normocephalic and atraumatic. She has dry mucosal membrane. She now has a right facial droop, which per her daughter is new. Neck veins are not distended. No carotid bruits visible. Skin: Warm, well perfused. Lungs are clear to auscultation anteriorly. No wheezes. Cardiac exam: S1, S2, regular rate. No significant murmurs. PMI is nondisplaced. Abdomen: Soft, nondistended. Extremities: Without edema, on limited exam. Neurological exam seems to show only the right facial droop.,DIAGNOSTIC/LABORATORY DATA: , EKGs as reviewed above. Her last ECG shows normalization of prior ST elevation in the inferior leads with Q waves and first-degree AV block, PR interval 280 milliseconds. Further lab shows sodium 135, potassium 4.2, chloride 98, bicarbonate 26, BUN 9, creatinine 0.8, glucose 162, troponin 0.17, INR 1.27, white blood cell count 1.3, hematocrit 31, platelet count of 179.,Chest x-ray, no significant pericardial effusion.,IMPRESSION: , The patient is a 69-year-old woman with metastatic non-small-cell lung cancer with a recent hemorrhagic pericardial effusion, now admitted with cerebrovascular accident and transient inferior myocardial infarction, which appears to be canalized. I will discuss this in detail with the patient and her daughter, and clearly, her situation is quite guarded with likely poor prognosis, which they are understanding of.,RECOMMENDATIONS:,1. I think it is reasonable to continue heparin, but clearly she would be at risk for hemorrhagic pericardial effusion recurrence.,2. Morphine is appropriate, especially for preload reduction and other comfort measures as appropriate.,3. Would avoid other blood thinners including Plavix, Integrilin, and certainly, she is not a candidate for a thrombolytic with which the patient and her daughter are in agreement with after a long discussion.,Other management as per the medical service. I have discussed the case with Dr. X of the hospitalist service who will be admitting the patient.

Mediastinal exploration and delayed primary chest closure. The patient is a 12-day-old infant who has undergone a modified stage I Norwood procedure with a Sano modification.

Cardiovascular / Pulmonary

Mediastinal Exploration

TITLE OF OPERATION:, Mediastinal exploration and delayed primary chest closure.,INDICATION FOR SURGERY:, The patient is a 12-day-old infant who has undergone a modified stage I Norwood procedure with a Sano modification. The patient experienced an unexplained cardiac arrest at the completion of the procedure, which required institution of extracorporeal membrane oxygenation for more than two hours following discontinuation of cardiopulmonary bypass. The patient has been successfully resuscitated with extracorporeal membrane oxygenation and was decannulated 48 hours ago. She did not meet the criteria for delayed primary chest closure.,PREOP DIAGNOSIS: , Open chest status post modified stage I Norwood procedure.,POSTOP DIAGNOSIS: , Open chest status post modified stage I Norwood procedure.,ANESTHESIA:, General endotracheal.,COMPLICATIONS:, None.,FINDINGS: , No evidence of intramediastinal purulence or hematoma. At completion of the procedure no major changes in hemodynamic performance.,DETAILS OF THE PROCEDURE: , After obtaining informed consent, the patient was brought to the room, placed on the operating room table in supine position. Following the administration of general endotracheal anesthesia, the chest was prepped and draped in the usual sterile fashion and all the chest drains were removed. The chest was then prepped and draped in the usual sterile fashion and previously placed segmental AlloDerm was removed. The mediastinum was then thoroughly irrigated with diluted antibiotic irrigation and both pleural cavities suctioned. Through a separate incision and another 15-French Blake drain was inserted and small titanium clips were utilized to mark the rightward aspect of the RV-PA connection as well as inferior most aspect of the ventriculotomy. The pleural spaces were opened widely and the sternum was then spilled with vancomycin paste and closed the sternum with steel wires. The subcutaneous tissue and skin were closed in layers. There was no evidence of significant increase in central venous pressure or desaturation. The patient tolerated the procedure well. Sponge and needle counts were correct times 2 at the end of the procedure. The patient was transferred to the Pediatric Intensive Care Unit shortly thereafter in critical but stable condition.,I was the surgical attending present in the operating room in charge of the surgical procedure throughout the entire length of the case.

cardiovascular / pulmonary, mediastinal exploration, delayed primary chest closure, extracorporeal membrane oxygenation, stage i norwood procedure, sano modification, chest closure, infant, mediastinal, exploration, closure, endotracheal, chest

Lexiscan myoview stress study. Chest discomfort. Normal stress/rest cardiac perfusion with no indication of ischemia. Normal LV function and low likelihood of significant epicardial coronary narrowing.

Cardiovascular / Pulmonary

Mayoview - 2

LEXISCAN MYOVIEW STRESS STUDY,REASON FOR THE EXAM: , Chest discomfort.,INTERPRETATION: , The patient exercised according to the Lexiscan study, received a total of 0.4 mg of Lexiscan IV injection. At peak hyperemic effect, 24.9 mCi of Myoview were injected for the stress imaging and earlier 8.2 mCi were injected for the resting and the usual SPECT and gated SPECT protocol was followed and the data was analyzed using Cedars-Sinai software. The patient did not walk because of prior history of inability to exercise long enough on treadmill.,The resting heart rate was 57 with the resting blood pressure 143/94. Maximum heart rate achieved was 90 with a maximum blood pressure unchanged.,EKG at rest showed sinus rhythm with no significant ST-T wave changes of reversible ischemia or injury. Subtle nonspecific in III and aVF were seen. Maximum stress test EKG showed inverted T wave from V4 to V6. Normal response to Lexiscan.,CONCLUSION: ,Maximal Lexiscan perfusion with subtle abnormalities non-conclusive. Please refer to the Myoview interpretation.,MYOVIEW INTERPRETATION: , The left ventricle appeared to be normal in size on both stress and rest with no change between the stress and rest with left ventricular end-diastolic volume of 115 and end-systolic of 51. EF estimated and calculated at 56%.,Cardiac perfusion reviewed, showed no reversible defect indicative of myocardium risk and no fixed defect indicative of myocardial scarring.,IMPRESSION:,1. Normal stress/rest cardiac perfusion with no indication of ischemia.,2. Normal LV function and low likelihood of significant epicardial coronary narrowing.,

cardiovascular / pulmonary, chest discomfort, lexiscan myoview stress study, mci, spect, gated spect, myoview, lexiscan, stress test, ekg, lexiscan myoview, lv function, coronary narrowing, heart rate, blood pressure, myoview interpretation, cardiac perfusion, cardiac, ischemia, perfusion, stress,

The patient had undergone mitral valve repair about seven days ago.

Cardiovascular / Pulmonary

Mediastinal Exploration & Right Atrium Repair

PREOPERATIVE DIAGNOSES:,1. Cardiac tamponade.,2. Status post mitral valve repair.,POSTOPERATIVE DIAGNOSES:,1. Cardiac tamponade.,2. Status post mitral valve repair.,PROCEDURE PERFORMED: , Mediastinal exploration with repair of right atrium.,ANESTHESIA: , General endotracheal.,INDICATIONS: , The patient had undergone mitral valve repair about seven days ago. He had epicardial pacing wires removed at the bedside. Shortly afterwards, he began to feel lightheaded and became pale and diaphoretic. He was immediately rushed to the operating room for cardiac tamponade following removal of epicardial pacing wires. He was transported immediately and emergently and remained awake and alert throughout the time period inspite of hypotension with the systolic pressure in the 60s-70s.,DETAILS OF PROCEDURE: ,The patient was taken emergently to the operating room and placed supine on the operating room table. His chest was prepped and draped prior to induction under general anesthesia. Incision was made through the previous median sternotomy chest incision. Wires were removed in the usual manner and the sternum was retracted. There were large amounts of dark blood filling the mediastinal chest cavity. Large amounts of clot were also removed from the pericardial well and chest. Systematic exploration of the mediastinum and pericardial well revealed bleeding from the right atrial appendix at the site of the previous cannulation. This was repaired with two horizontal mattress pledgeted #5-0 Prolene sutures. An additional #0 silk tie was also placed around the base of the atrial appendage for further hemostasis. No other sites of bleeding were identified. The mediastinum was then irrigated with copious amounts of antibiotic saline solution. Two chest tubes were then placed including an angled chest tube into the pericardial well on the inferior border of the heart, as well as straight mediastinal chest tube. The sternum was then reapproximated with stainless steel wires in the usual manner and the subcutaneous tissue was closed in multiple layers with running Vicryl sutures. The skin was then closed with a running subcuticular stitch. The patient was then taken to the Intensive Care Unit in a critical but stable condition.

cardiovascular / pulmonary, mitral valve repair, exploration, median sternotomy chest incision, pericardial, mediastinal exploration, pacing wires, cardiac tamponade, chest tubes, mitral valve, valve repair, mediastinal, mitral, wires, atrium, repair,

Lung, wedge biopsy right lower lobe and resection right upper lobe. Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.

Cardiovascular / Pulmonary

Lung Biopsy Pathology Report

CLINICAL HISTORY:, A 48-year-old smoker found to have a right upper lobe mass on chest x-ray and is being evaluated for chest pain. PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan. The lower lobe mass was approximately 1 cm in diameter and the upper lobe mass was 4 cm to 5 cm in diameter. The patient was referred for surgical treatment.,SPECIMEN:,A. Lung, wedge biopsy right lower lobe,B. Lung, resection right upper lobe,C. Lymph node, biopsy level 2 and 4,D. Lymph node, biopsy level 7 subcarinal,FINAL DIAGNOSIS:,A. Wedge biopsy of right lower lobe showing: Adenocarcinoma, Grade 2, Measuring 1 cm in diameter with invasion of the overlying pleura and with free resection margin.,B. Right upper lobe lung resection showing: Adenocarcinoma, grade 2, measuring 4 cm in diameter with invasion of the overlying pleura and with free bronchial margin. Two (2) hilar lymph nodes with no metastatic tumor.,C. Lymph node biopsy at level 2 and 4 showing seven (7) lymph nodes with anthracosis and no metastatic tumor.,D. Lymph node biopsy, level 7 subcarinal showing (5) lymph nodes with anthracosis and no metastatic tumor.,COMMENT: ,The morphology of the tumor seen in both lobes is similar and we feel that the smaller tumor involving the right lower lobe is most likely secondary to transbronchial spread from the main tumor involving the right upper lobe. This suggestion is supported by the fact that no obvious vascular or lymphatic invasion is demonstrated and adjacent to the smaller tumor, there is isolated nests of tumor cells within the air spaces. Furthermore, immunoperoxidase stain for Ck-7, CK-20 and TTF are performed on both the right lower and right upper lobe nodule. The immunohistochemical results confirm the lung origin of both tumors and we feel that the tumor involving the right lower lobe is due to transbronchial spread from the larger tumor nodule involving the right upper lobe.,

cardiovascular / pulmonary, pet scan, wedge biopsy, morphology, lung wedge biopsy, lymph node biopsy, lymph node, lower lobe, tumor, biopsy, lobe, lung, mass, lymph, node

Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, and pharmacologic thrombolysis following placement of a vena caval filter.

Cardiovascular / Pulmonary

Lymphoblastic Leukemia - Consult

CHIEF COMPLAINT: , Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, right iliac vein and inferior vena cava (IVC), status post balloon angioplasty, and mechanical and pharmacologic thrombolysis following placement of a vena caval filter.,HISTORY OF PRESENT ILLNESS: , The patient was transferred here the evening of 02/23/2007 from Hospital with a new diagnosis of high-risk acute lymphoblastic leukemia based on confirmation by flow cytometry of peripheral blood lymphoblasts that afternoon. History related to this illness probably dates back to October of 2006 when he had onset of swelling and discomfort in the left testicle with what he described as a residual "lump" posteriorly. The left testicle has continued to be painful off and on since. In early November, he developed pain in the posterior part of his upper right leg, which he initially thought was related to skateboarding and muscle strain. Physical therapy was prescribed and the discomfort temporarily improved. In December, he noted onset of increasing fatigue. He used to work out regularly, lifting lifts, doing abdominal exercises, and playing basketball and found he did not have energy to pursue these activities. He has lost 10 pounds since December and feels his appetite has decreased. Night sweats and cough began in December, for which he was treated with a course of Augmentin. However, both of these problems have continued. He also began taking Accutane for persistent acne in December (this agent was stopped on 02/19/2007). Despite increasing fatigue and lethargy, he continues his studies at University of Denver, has a biology major (he aspires to be an ophthalmologist).,The morning of 02/19/2007, he awakened with severe right inguinal and right lower quadrant pain. He was seen in Emergency Room where it was noted that he had an elevated WBC of 18,000. CT scan of the abdomen was obtained to rule out possible appendicitis and on that CT, a large clot in the inferior vena cava extending to the right iliac and femoral veins was found. He promptly underwent appropriate treatment in interventional radiology with the above-noted angioplasty and placement of a vena caval filter followed by mechanical and pharmacologic thrombolysis. Repeat ultrasound there on 02/20/2007 showed no evidence of deep venous thrombosis (DVT). Continuous intravenous unfractionated heparin infusion was continued. Because there was no obvious cause of this extensive thrombosis, occult malignancy was suspected. Appropriate blood studies were obtained and he underwent a PET/CT scan as part of his diagnostic evaluation. This study showed moderately increased diffuse bone marrow metabolic activity. Because the WBC continued to rise and showed a preponderance of lymphocytes, the smear was reviewed by pathologist, Sheryl Asplund, M.D., and flow cytometry was performed on the peripheral blood. These studies became available the afternoon of 02/23/2007, and confirmed the diagnosis of precursor-B acute lymphoblastic leukemia. The patient was transferred here after stopping of the continuous infusion heparin and receiving a dose of Lovenox 60 mg subcutaneously for further diagnostic evaluation and management of the acute lymphoblastic leukemia (ALL).,ALLERGIES: , NO KNOWN DRUG ALLERGIES. HE DOES SEEM TO REACT TO CERTAIN ADHESIVES.,CURRENT MEDICATIONS: ,1. Lovenox 60 mg subcutaneously q.12h. initiated.,2. Coumadin 5 mg p.o., was administered on 02/19/2007 and 02/22/2007.,3. Protonix 40 mg intravenous (IV) daily.,4. Vicodin p.r.n.,5. Levaquin 750 mg IV on 02/23/2007.,IMMUNIZATIONS: , Up-to-date.,PAST SURGICAL HISTORY: ,The treatment of the thrombosis as noted above on 02/19/2007 and 02/20/2007.,FAMILY HISTORY: ,Two half-brothers, ages 26 and 28, both in good health. Parents are in good health. A maternal great-grandmother had a deep venous thrombosis (DVT) of leg in her 40s. A maternal great-uncle developed leukemia around age 50. A maternal great-grandfather had bone cancer around age 80. His paternal grandfather died of colon cancer at age 73, which he had had since age 68. Adult-onset diabetes is present in distant relatives on both sides.,SOCIAL HISTORY: ,The patient is a student at the University majoring in biology. He lives in a dorm there. His parents live in Breckenridge. He admits to having smoked marijuana off and on with friends and drinking beer off and on as well.,REVIEW OF SYSTEMS: , He has had emesis off and on related to Vicodin and constipation since 02/19/2007, also related to pain medication. He has had acne for about two years, which he describes as mild to moderate. He denied shortness of breath, chest pain, hemoptysis, dyspnea, headaches, joint pains, rashes, except where he has had dressings applied, and extremity pain except for the right leg pain noted above.,PHYSICAL EXAMINATION: ,GENERAL: Alert, cooperative, moderately ill-appearing young man.,VITAL SIGNS: At the time of admission, pulse was 94, respirations 20, blood pressure 120/62, temperature 98.7, height 171.5 cm, weight 63.04 kg, and pulse oximetry on room air 95%.,HAIR AND SKIN: Mild facial acne.,HEENT: Extraocular muscles (EOMs) intact. Pupils equal, round, and reactive to light and accommodation (PERRLA), fundi normal.,CARDIOVASCULAR: A 2/6 systolic ejection murmur (SEM), regular sinus rhythm (RSR).,LUNGS: Clear to auscultation with an occasional productive cough.,ABDOMEN: Soft with mild lower quadrant tenderness, right more so than left; liver and spleen each decreased 4 cm below their respective costal margins.,MUSCULOSKELETAL: Mild swelling of the dorsal aspect of the right foot and distal right leg. Mild tenderness over the prior catheter entrance site in the right popliteal fossa and mild tenderness over the right medial upper thigh.,GENITOURINARY: Testicle exam disclosed no firm swelling with mild nondiscrete fullness in the posterior left testicle.,NEUROLOGIC: Exam showed him to be oriented x4. Normal fundi, intact cranial nerves II through XII with downgoing toes, symmetric muscle strength, and decreased patellar deep tendon reflexes (DTRs).,LABORATORY DATA: ,White count 25,500 (26 neutrophils, 1 band, 7 lymphocytes, 1 monocyte, 1 myelocyte, 64 blasts), hemoglobin 13.3, hematocrit 38.8, and 312,000 platelets. Electrolytes, BUN, creatinine, phosphorus, uric acid, AST, ALT, alkaline phosphatase, and magnesium were all normal. LDH was elevated to 1925 units/L (upper normal 670), and total protein and albumin were both low at 6.2 and 3.4 g/dL respectively. Calcium was also slightly low at 8.8 mg/dL. Low molecular weight heparin test was low at 0.27 units/mL. PT was 11.8, INR 1.2, and fibrinogen 374. Urinalysis was normal.,ASSESSMENT: , 1. Newly diagnosed high-risk acute lymphoblastic leukemia.,2. Deep vein thrombosis of the distal iliac and common femoral/right femoral and iliac veins, status post vena caval filter placement and mechanical and thrombolytic therapy, on continued anticoagulation.,3. Probable chronic left epididymitis.,PLAN: , 1. Proceed with diagnostic bone marrow aspirate/biopsy and lumbar puncture (using a #27-gauge pencil-tip needle for minimal trauma) as soon as these procedures can be safely done with regard to the anticoagulation status.,2. Prompt reassessment of the status of the deep venous thrombosis with Doppler studies.,3. Ultrasound/Doppler of the testicles.,4. Maintain therapeutic anticoagulation as soon as the diagnostic procedures for ALL can be completed.,

The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.

Cardiovascular / Pulmonary

Lung Biopsy Pathology Report - 1

GROSS DESCRIPTION:,A. Received fresh labeled with patient's name, designated 'right upper lobe wedge', is an,8.0 x 3.5 x 3.0 cm wedge of lung which has an 11.5 cm staple line. There is a 0.8 x,0.7 x 0.5 cm sessile tumor with surrounding pleural puckering.,B. Received fresh, labeled with patient's name, designated "lymph node', is a 1.7 cm possible lymph node with anthracotic pigment.,C. Received fresh labeled with patient's name, designated 'right upper lobe', is a 16.0 x,14.5 x 6.0 cm lobe of lung. The lung is inflated with formalin. There is a 12.0 cm staple line on the lateral surface, inked blue. There is a 1.3 x 1.1 x 0.8 cm subpleural firm ill-defined mass, 2.2 cm from the bronchial margin and 1.5 cm from the previously described staple line. The overlying pleura is puckered.,D. Received fresh, labeled with patient's name, designated '4 lymph nodes', is a 2.0 x 2.0 x 2.0 cm aggregate of lymphoid material with anthracotic pigment and adipose tissue.,E. Received fresh, labeled with patient's name, designated 'subcarinal lymph node', is a,2.0 x 1.7 x 0.8 cm aggregate of lymphoid material with anthracotic pigment .,FINAL DIAGNOSIS:,A. Right upper lobe wedge lung biopsy: Poorly differentiated non-small cell carcinoma. Tumor Size: 0.8 cm. Arterial (large vessel) invasion: Not seen. Small vessel (lymphatic) invasion: Not seen. Pleural invasion: Not identified. Margins of excision: Negative for malignancy.,B. Biopsy, 10R lymph node: Anthracotically pigmented lymphoid tissue, negative for malignancy.,C. Right upper lobe, lung: Moderately differentiated non-small cell carcinoma,(adenocarcinoma). Tumor Size: 1.3 cm. Arterial (large vessel) invasion: Present. Small vessel (lymphatic) invasion: Not seen. Pleural invasion: Not identified. Margins of excision: Negative for malignancy.,D. Biopsy, 4R lymph nodes: Lymphoid tissue, negative for malignancy.,E. Biopsy, subcarinal lymph node: Lymphoid tissue, negative for malignancy.,COMMENTS:, Pathologic examination reveals two separate tumors in the right upper lobe. They appear histologically distinct, suggesting they are separate primary tumors (pT1). The right upper lobe wedge biopsy (part A) shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy. The right upper lobe carcinoma identified in the resection (part C) is a moderately differentiated adenocarcinoma with obvious gland formation.

cardiovascular / pulmonary, lung biopsy, wedge, lobe, pathologic, lymph node', node', lymphoid, malignancy, lung, lymph, biopsy

Right upper lung lobectomy. Mediastinal lymph node dissection

Cardiovascular / Pulmonary

Lobectomy & Lymph Node Dissection

OPERATION,1. Right upper lung lobectomy.,2. Mediastinal lymph node dissection.,ANESTHESIA,1. General endotracheal anesthesia with dual-lumen tube.,2. Thoracic epidural.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room, and general endotracheal anesthesia was administered with a dual-lumen tube. Next, the patient was placed in the left lateral decubitus position, and his right chest was prepped and draped in the standard surgical fashion. We used a #10-blade scalpel to make an incision in the skin approximately 1 fingerbreadth below the angle of the scapula. Dissection was carried down in a muscle-sparing fashion using Bovie electrocautery. The 5th rib was counted, and the 6th interspace was entered. The lung was deflated. We identified the major fissure. We then began by freeing up the inferior pulmonary ligament, which was done with Bovie electrocautery. Next, we used Bovie electrocautery to dissect the pleura off the lung. The pulmonary artery branches to the right upper lobe of the lung were identified. Of note was the fact that there was a visible, approximately 4 x 4-cm mass in the right upper lobe of the lung without any other metastatic disease palpable. As mentioned, a combination of Bovie electrocautery and sharp dissection was used to identify the pulmonary artery branches to the right upper lobe of the lung. Next, we began by ligating the pulmonary artery branches of the right upper lobe of the lung. This was done with suture ligature in combination with clips. After taking the pulmonary artery branches of the right upper lobe of the lung, we used a combination of blunt dissection and sharp dissection with Metzenbaum scissors to separate out the pulmonary vein branch of the right upper lobe of the lung. This likewise was ligated with a 0 silk. It was stick-tied with a 2-0 silk. It was then divided. Next we dissected out the bronchial branch to the right upper lobe of the lung. A curved Glover was placed around the bronchus. Next a TA-30 stapler was fired across the bronchus. The bronchus was divided with a #10-blade scalpel. The specimen was handed off. We next performed a mediastinal lymph node dissection. Clips were applied to the base of the feeding vessels to the lymph nodes. We inspected for any signs of bleeding. There was minimal bleeding. We placed a #32-French anterior chest tube, and a #32-French posterior chest tube. The rib space was closed with #2 Vicryl in an interrupted figure-of-eight fashion. A flat Jackson-Pratt drain, #10 in size, was placed in the subcutaneous flap. The muscle layer was closed with a combination of 2-0 Vicryl followed by 2-0 Vicryl, followed by 4-0 Monocryl in a running subcuticular fashion. Sterile dressing was applied. The instrument and sponge count was correct at the end of the case. The patient tolerated the procedure well and was transferred to the PACU in good condition.

cardiovascular / pulmonary, mediastinal, thoracic, epidural, lymph node dissection, lymph node, artery branches, lobectomy, lung, anesthesia, bovie, electrocautery, lymph, pulmonary, branches

VATS right middle lobectomy, fiberoptic bronchoscopy, mediastinal lymph node sampling, tube thoracostomy x2, multiple chest wall biopsies and excision of margin on anterior chest wall adjacent to adherent tumor.

Cardiovascular / Pulmonary

Lobectomy - VATS

PREOPERATIVE DIAGNOSIS:, Right middle lobe lung cancer.,POSTOPERATIVE DIAGNOSIS: , Right middle lobe lung cancer.,PROCEDURES PERFORMED:,1. VATS right middle lobectomy.,2. Fiberoptic bronchoscopy thus before and after the procedure.,3. Mediastinal lymph node sampling including levels 4R and 7.,4. Tube thoracostomy x2 including a 19-French Blake and a 32-French chest tube.,5. Multiple chest wall biopsies and excision of margin on anterior chest wall adjacent to adherent tumor.,ANESTHESIA: ,General endotracheal anesthesia with double-lumen endotracheal tube.,DISPOSITION OF SPECIMENS: , To pathology both for frozen and permanent analysis.,FINDINGS:, The right middle lobe tumor was adherent to the anterior chest wall. The adhesion was taken down, and the entire pleural surface along the edge of the adhesion was sent for pathologic analysis. The final frozen pathology on this entire area returned as negative for tumor. Additional chest wall abnormalities were biopsied and sent for pathologic analysis, and these all returned separately as negative for tumor and only fibrotic tissue. Several other biopsies were taken and sent for permanent analysis of the chest wall. All of the biopsy sites were additionally marked with Hemoclips. The right middle lobe lesion was accompanied with distal pneumonitis and otherwise no direct involvement of the right upper lobe or right lower lobe.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,CONDITION OF THE PATIENT AFTER SURGERY: , Stable.,HISTORY OF PROCEDURE:, This patient is well known to our service. He was admitted the night before surgery and given hemodialysis and had close blood sugar monitoring in control. The patient was subsequently taken to the operating room on April 4, 2007, was given general anesthesia and was endotracheally intubated without incident. Although, he had markedly difficult airway, the patient had fiberoptic bronchoscopy performed all the way down to the level of the subsegmental bronchi. No abnormalities were noted in the entire tracheobronchial tree, and based on this, the decision was made to proceed with the surgery. The patient was kept in the supine position, and the single-lumen endotracheal tube was removed and a double-lumen tube was placed. Following this, the patient was placed into the left lateral decubitus position with the right side up and all pressure points were padded. Sterile DuraPrep preparation on the right chest was placed. A sterile drape around that was also placed. The table was flexed to open up the intercostal spaces. A second bronchoscopy was performed to confirm placement of the double-lumen endotracheal tube. Marcaine was infused into all incision areas prior to making an incision. The incisions for the VATS right middle lobectomy included a small 1-cm incision for the auscultatory incision approximately 4 cm inferior to the inferior tip of the scapula. The camera port was in the posterior axillary line in the eighth intercostal space through which a 5-mm 30-degree scope was used. Third incision was an anterior port, which was approximately 2 cm inferior to the inframammary crease and the midclavicular line in the anterior sixth intercostal space, and the third incision was a utility port, which was a 4 cm long incision, which was approximately one rib space below the superior pulmonary vein. All of these incisions were eventually created during the procedure. The initial incision was the camera port through which, under direct visualization, an additional small 5-mm port was created just inferior to the anterior port. These two ports were used to identify the chest wall lesions, which were initially thought to be metastatic lesions. Multiple biopsies of the chest wall lesions were taken, and the decision was made to also insert the auscultatory incision port. Through these three incisions, the initial working of the diagnostic portion of the chest wall lesion was performed. Multiple biopsies were taken of the entire chest wall offers and specimens came back as negative. The right middle lobe was noted to be adherent to the anterior chest wall. This area was taken down and the entire pleural surface along this area was taken down and sent for frozen pathologic analysis. This also returned as negative with only fibrotic tissue and a few lymphocytes within the fibrotic tissue, but no tumor cells. Based on this, the decision was made to not proceed with chest wall resection and continue with right middle lobectomy. Following this, the anterior port was increased in size and the utility port was made and meticulous dissection from an anterior to posterior direction was performed. The middle lobe branch of the right superior pulmonary vein was initially dissected and stapled with vascular load 45-mm EndoGIA stapler. Following division of the right superior pulmonary vein, the right middle lobe bronchus was easily identified. Initially, this was thought to be the main right middle lobe bronchus, but in fact it was the medial branch of the right middle lobe bronchus. This was encircled and divided with a blue load stapler with a 45-mm EndoGIA. Following division of this, the pulmonary artery was easily identified. Two branches of the pulmonary artery were noted to be going into the right middle lobe. These were individually divided with a vascular load after encircling with a right angle clamp. The vascular staple load completely divided these arterial branches successfully from the main pulmonary artery trunk, and following this, an additional branch of the bronchus was noted to be going to the right middle lobe. A fiberoptic bronchoscopy was performed intraoperatively and confirmed that this was in fact the lateral branch of the right middle lobe bronchus. This was divided with a blue load stapler 45 mm EndoGIA. Following division of this, the minor and major fissures were completed along the edges of the right middle lobe separating the right upper lobe from the right middle lobe as well as the right middle lobe from the right lower lobe. Following complete division of the fissure, the lobe was put into an EndoGIA bag and taken out through the utility port. Following removal of the right middle lobe, a meticulous lymph node dissection sampling was performed excising the lymph node package in the 4R area as well as the 7 lymph node package. Node station 8 or 9 nodes were easily identified, therefore none were taken. The patient was allowed to ventilate under water on the right lung with no obvious air leaking noted. A 19-French Blake was placed into the posterior apical position and a 32-French chest tube was placed in the anteroapical position. Following this, the patient's lung was allowed to reexpand fully, and the patient was checked for air leaking once again. Following this, all the ports were closed with 2-0 Vicryl suture used for the deeper tissue, and 3-0 Vicryl suture was used to reapproximate the subcutaneous tissue and 4-0 Monocryl suture was used to close the skin in a running subcuticular fashion. The patient tolerated the procedure well, was extubated in the operating room and taken to the recovery room in stable condition.

cardiovascular / pulmonary, middle lobe, endogia, fiberoptic, mediastinal lymph node, vats, bronchoscopy, chest tube, chest wall, endotracheal tube, endotracheally, lobectomy, lung cancer, pneumonitis, sampling, thoracostomy, utility port, lumen endotracheal tube, superior pulmonary vein, chest wall lesions, anterior chest wall, middle lobectomy, fiberoptic bronchoscopy, anterior chest, lymph node, node, port, chest, bronchus, tumor, pulmonary, incision,

Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and "Right upper lobe lung".

Cardiovascular / Pulmonary

Lung adenocarcinoma Path Report

CLINICAL HISTORY: ,Probable right upper lobe lung adenocarcinoma.,SPECIMEN: , Lung, right upper lobe resection.,GROSS DESCRIPTION:, Specimen is received fresh for frozen section, labeled with the patient's identification and "Right upper lobe lung". It consists of one lobectomy specimen measuring 16.1 x 10.6 x,4.5.cm. The specimen is covered by a smooth, pink-tan and gray pleural surface which is largely unremarkable. Sectioning reveals a round, ill-defined, firm, tan-gray mucoid mass. This mass measures 3.6 x 3.3 x 2.7 cm and is located 3.7 cm from the closest surgical margin and 3.9 cm from the hilum. There is no necrosis or hemorrhage evident. The tumor grossly appears to abut, but not invade through, the visceral pleura, and the overlying pleura is puckered.,FINAL DIAGNOSIS:, Right lung, upper lobe, lobectomy: Bronchioloalveolar carcinoma, mucinous type,COMMENT:, Right upper lobe, lobectomy.,Tumor type: Bronchioloalveolar carcinoma, mucinous type.,Histologic grade: Well differentiated.,Tumor size (greatest diameter): 3.6 cm.,Blood/lymphatic vessel invasion: Absent.,Perineural invasion: Absent.,Bronchial margin: Negative.,Vascular margin: Negative.,Inked surgical margin: Negative.,Visceral pleura: Not involved.,In situ carcinoma: Absent.,Non-neoplastic lung: Emphysema.,Hilar lymph nodes: Number of positive lymph nodes: 0; Total number of lymph nodes: 1.,P53 immunohistochemical stain is negative in the tumor.

cardiovascular / pulmonary, bronchioloalveolar carcinoma, mucinous, mucoid mass, lymph nodes, upper lobe, visceral, bronchioloalveolar, carcinoma, lymph, pleural, margin, tumor, adenocarcinoma, specimen, lobe, lung,

Right lower lobectomy, right thoracotomy, extensive lysis of adhesions, mediastinal lymphadenectomy.

Cardiovascular / Pulmonary

Lobectomy & Lymphadenectomy

PREOPERATIVE DIAGNOSIS: ,Right lower lobe mass, possible cancer.,POSTOPERATIVE DIAGNOSIS: , Non-small cell carcinoma of the right lower lobe.,PROCEDURES:,1. Right thoracotomy.,2. Extensive lysis of adhesions.,3. Right lower lobectomy.,4. Mediastinal lymphadenectomy.,ANESTHESIA: , General.,DESCRIPTION OF THE PROCEDURE: , The patient was taken to the operating room and placed on the operating table in the supine position. After an adequate general anesthesia was given, she was placed in the left lateral decubitus and the right chest was prepped and draped in the sterile fashion. Lateral thoracotomy was performed on the right side anterior to the tip of the scapula, and this was carried down through the subcutaneous tissue. The latissimus dorsi muscle was partially transected and then the serratus was reflected anteriorly. The chest was entered through the fifth intercostal space. A retractor was placed and then extensive number of adhesions between the lung and the pleura were lysed carefully with sharp and blunt dissection. The right lower lobe was identified. There was a large mass in the superior segment of the lobe, which was very close to the right upper lobe, and because of the adhesions, it could not be told if the tumor was extending into the right upper lobe, but it appeared that it did not. Dissection was then performed at the lower lobe of the fissure, and a GIA stapler was placed through here to separate the tumor from the upper lobe including a small segment of the upper lobe with the lower lobe. Then, dissection of the hilum was performed, and the branches of the pulmonary artery to the lower lobe were ligated with #2-0 silk freehand ties proximally and distally and #3-0 silk transfixion stitches and then transected. The inferior pulmonary vein was dissected after dividing the ligament, and it was stapled proximally and distally with a TA30 stapler and then transected. Further dissection of the fissure allowed for its completion with a GIA stapler and then the bronchus was identified and dissected. The bronchus was stapled with a TA30 bronchial stapler and then transected, and the specimen was removed and sent to the Pathology Department for frozen section diagnosis. The frozen section diagnosis was that of non-small cell carcinoma, bronchial margins free and pleural margins free. The mediastinum was then explored. No nodes were identified around the pulmonary ligament or around the esophagus. Subcarinal nodes were dissected, and hemostasis was obtained with clips. The space below and above the osseous was opened, and the station R4 nodes were dissected. Hemostasis was obtained with clips and with electrocautery. All nodal tissue were sent to Pathology as permanent specimen. Following this, the chest was thoroughly irrigated and aspirated. Careful hemostasis was obtained and a couple of air leaks were controlled with #6-0 Prolene sutures. Then, two #28 French chest tubes were placed in the chest, one posteriorly and one anteriorly, and secured to the skin with #2-0 nylon stitches. The incision was then closed with interrupted #2-0 Vicryl pericostal stitches. A running #1 PDS on the muscle layer, a running 2-0 PDS in the subcutaneous tissue, and staples on the skin. A sterile dressing was applied, and the patient was then awakened and transferred to the following Intensive Care Unit in stable and satisfactory condition.,ESTIMATED BLOOD LOSS: , 100 mL.,TRANSFUSIONS:, None.,COMPLICATIONS:, None.,CONDITION: , Condition of the patient on arrival to the intensive care unit was satisfactory.

cardiovascular / pulmonary, right lower lobe, gia stapler, mediastinal, non-small cell carcinoma, cancer, frozen section, hilum, lobectomy, lymphadenectomy, lysis of adhesions, pleura, thoracotomy, upper lobe, lower lobectomy, adhesions, chest

Left lower extremity venous Doppler ultrasound

Cardiovascular / Pulmonary

Lower Extremity Venous Doppler

LEFT LOWER EXTREMITY VENOUS DOPPLER ULTRASOUND,REASON FOR EXAM: , Status post delivery five weeks ago presenting with left calf pain.,INTERPRETATIONS: , There was normal flow, compression and augmentation within the right common femoral, superficial femoral and popliteal veins. Lymph nodes within the left inguinal region measure up to 1 cm in short-axis.,IMPRESSION: , Lymph nodes within the left inguinal region measure up to 1 cm in short-axis, otherwise no evidence for left lower extremity venous thrombosis.

cardiovascular / pulmonary, popliteal veins, superficial femoral, common femoral, inguinal region, lymph nodes, venous doppler, lower extremity, lymph, inguinal, axis, doppler, extremity, venous,

Lower Extremity Arterial Doppler

Cardiovascular / Pulmonary

Lower Extremity Arterial Doppler

RIGHT LOWER EXTREMITY:, The arterial system was visualized showing triphasic waveform from the common femoral to popliteal and biphasic waveform at the posterior tibial artery with ankle brachial index of 0/8.,LEFT LOWER EXTREMITY:, The arterial system was visualized with triphasic waveform from the common femoral to the popliteal artery, with biphasic waveform at the posterior tibial artery. Ankle brachial index of 0.9.,IMPRESSION: , Mild bilateral lower extremity arterial obstructive disease.,

cardiovascular / pulmonary, lower extremity arterial doppler, posterior tibial artery, ankle brachial index, arterial doppler, triphasic waveform, common femoral, biphasic waveform, tibial artery, ankle brachial, brachial index, lower extremity, doppler, triphasic, femoral, popliteal, brachial, waveform, extremity, arterial,

Left lower lobectomy.

Cardiovascular / Pulmonary

Lobectomy - Left Lower

OPERATION: , Left lower lobectomy.,OPERATIVE PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed in the supine position. After general endotracheal anesthesia was induced, the appropriate monitoring devices were placed. The patient was placed in the right lateral decubitus position. The left chest and back were prepped and draped in a sterile fashion. A right lateral thoracotomy incision was made. Subcutaneous flaps were raised. The anterior border of the latissimus dorsi was freed up, and the muscle was retracted posteriorly. The posterior border of the pectoralis was freed up and it was retracted anteriorly. The 5th intercostal space was entered.,The inferior pulmonary ligament was then taken down with electrocautery. The major fissure was then taken down and arteries identified. The artery was dissected free and it was divided with an Endo GIA stapler. The vein was then dissected free and divided with an Endo GIA stapler. The bronchus was then cleaned of all nodal tissue. A TA-30 green loaded stapler was then placed across this, fired, and main bronchus divided distal to the stapler.,Then the lobe was removed and sent to pathology where margins were found to be free of tumor. Level 9, level 13, level 11, and level 6 nodes were taken for permanent cell specimen. Hemostasis noted. Posterior 28-French and anterior 24-French chest tubes were placed.,The wounds were closed with #2 Vicryl. A subcutaneous drain was placed. Subcutaneous tissue was closed with running 3-0 Dexon, skin with running 4-0 Dexon subcuticular stitch.

cardiovascular / pulmonary, lower lobectomy, electrocautery, endo gia stapler, subcutaneous drain, endotracheal, subcutaneous, lobectomy,

Patient is here to discuss possible open lung biopsy.

Cardiovascular / Pulmonary

Lung Biopsy Discussion

CHART NOTE:, She is here to discuss possible open lung biopsy that she has actually scheduled for tomorrow. Dr. XYZ had seen her because of her complaints of shortness of breath. Then she had the pulmonary function test and CT scan and he felt that she probably had usual interstitial pneumonitis, but wanted her to have an open lung biopsy so he had her see Dr. XYZ Estep. He had concurred with Dr. XYZ that an open lung biopsy was appropriate and she was actually scheduled for this but both Dr. XYZ and I were unavailable before the procedure was originally scheduled so he had it delayed so that she could talk with us prior to having the biopsy. She was ready to go ahead with this and felt that it was important she find out why she is short of breath. She is very concerned about the findings on her CAT scan and pulmonary function test. She seemed alarmed to report that Dr. XYZ had found that her lung capacity was reduced to 60% of what should be normal. However, I told her that two years ago Dr. XYZ did pulmonary function studies which showed the same change in function. And that really her pulmonary function test, at least compared from two years ago, had not really changed over this period of time. After discussing the serious nature of an open lung biopsy, the fact that her pulmonary function studies have not changed in two years, the fact that she likely has a number of other things that are contributing to her being out of breath, which is deconditioning and obesity, she seemed comfortable with the thought of simply monitoring this a little bit longer before undergoing something as risky as an open lung biopsy. In fact when I called Dr. XYZ to talk to him about cancelling the procedure, he stated he would be very uncomfortable with doing an open lung biopsy on someone with pulmonary function studies which had not changed. I also explained to patient that I did not think Dr. XYZ was aware that she had had pulmonary function studies two years previously and certainly did not know that there results of those. And also I spoke with Dr. XYZ who agreed that although the two different tests may have some minor differences accounting for some of the similarity in results that may or may not be completely accurate, that generally a person with progressive interstitial lung disease without a fairly substantial change on pulmonary function tests even if they were done at different facilities.,I had a 30-minute discussion with patient about all of this and showed her the different test results and had a lengthy talk with her about the open lung biopsy and she ultimately felt very uncomfortable with going ahead and decided to cancel it. I also told her we could continue to monitor her breathing problems and continue to monitor her CAT scan, x-ray, and pulmonary function tests. And if there was some sign that this was a progressive problem, she could still go ahead with the lung biopsy. But she needed to understand that the treatment and likely diagnosis found from an open lung biopsy were not highly likely to be of any great help to her. She understands that the diagnoses made from open lung biopsy are not all that specific and that the treatment for the few specific things that can be detected are not often well tolerated or extremely helpful.,We are going to see her back in a month to see how her breathing is doing. We will cancel her open lung biopsy for tomorrow and decide whether she should follow up with a pulmonologist at that time. I told her I would try to talk to her sister sometime in the next day or two.

cardiovascular / pulmonary, discuss, interstitial pneumonitis, lung biopsy, lung capacity, pulmonary function test, shortness of breath, pulmonary function studies, pulmonary function, function, biopsy, lung, interstitial, pulmonaryNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The patient is a 65-year-old female who underwent left upper lobectomy for stage IA non-small cell lung cancer. She returns for a routine surveillance visit. The patient has no evidence of disease now status post left upper lobectomy for stage IA non-small cell lung cancer 13 months ago.

Cardiovascular / Pulmonary

Lobectomy - Followup

HISTORY OF PRESENT ILLNESS: , The patient is a 65-year-old female who underwent left upper lobectomy for stage IA non-small cell lung cancer. She returns for a routine surveillance visit.,She has undergone since her last visit an abdominopelvic CT, which shows an enlarging simple cyst of the left kidney. She underwent barium swallow, which demonstrates a small sliding hiatal hernia with minimal reflux. She has a minimal delayed emptying secondary tertiary contractions. PA and lateral chest x-ray from the 11/23/09 was also reviewed, which demonstrates no lesions or infiltrates. Review of systems, the patient continues to have periodic odynophagia and mid thoracic dysphagia. This most likely is secondary to tertiary contractions with some delayed emptying. She has also had increased size of the left calf without tenderness, which has not resolved over the past several months. She has had a previous DVT in 1975 and 1985. She denies weight loss, anorexia, fevers, chills, headaches, new aches or pains, cough, hemoptysis, shortness of breath at rest, or dyspnea on exertion.,MEDICATIONS: , Aspirin 81 mg p.o. q.d., Spiriva 10 mcg q.d., and albuterol p.r.n.,PHYSICAL EXAMINATION: , BP: 117/78. RR: 18. P: 93.,WT: 186 lbs. RAS: 100%.,HEENT: Mucous membranes are moist. No cervical or supraclavicular lymphadenopathy.,LUNGS: Clear to auscultation bilaterally.,CARDIAC: Regular rate and rhythm without murmurs.,EXTREMITIES: No cyanosis, clubbing or edema.,NEURO: Alert and oriented x3. Cranial nerves II through XII intact.,ASSESSMENT: , The patient has no evidence of disease now status post left upper lobectomy for stage IA non-small cell lung cancer 13 months ago.,PLAN: ,She is to return to clinic in six months with a chest CT. She was given a prescription for an ultrasound of the left lower extremity to rule out DVT. She will be called with the results. She was given a prescription for nifedipine 10 mg p.o. t.i.d. p.r.n. esophageal spasm.

cardiovascular / pulmonary, non-small cell lung cancer, lobectomy, lung cancer, non-small cell, lung, cancer

Lightheaded, dizziness, and palpitation. This morning, the patient experienced symptoms of lightheaded, dizziness, felt like passing out; however, there was no actual syncope. During the episode, the patient describes symptoms of palpitation and fluttering of chest. She relates the heart was racing. By the time when she came into the Emergency Room, her EKG revealed normal sinus rhythm. No evidence of arrhythmia.

Cardiovascular / Pulmonary

Lightheaded & Dizziness

REASON FOR CONSULTATION: , Lightheaded, dizziness, and palpitation.,HISTORY OF PRESENT ILLNESS: , The patient is a 50-year-old female who came to the Emergency Room. This morning, the patient experienced symptoms of lightheaded, dizziness, felt like passing out; however, there was no actual syncope. During the episode, the patient describes symptoms of palpitation and fluttering of chest. She relates the heart was racing. By the time when she came into the Emergency Room, her EKG revealed normal sinus rhythm. No evidence of arrhythmia. The patient had some cardiac workup in the past, results are as mentioned below. Denies any specific chest pain. Activities fairly stable. She is actively employed. No other cardiac risk factor in terms of alcohol consumption or recreational drug use, caffeinated drink use or over-the-counter medication usage.,CORONARY RISK FACTORS: , No history of hypertension or diabetes mellitus. Nonsmoker. Cholesterol normal. No history of established coronary artery disease and family history noncontributory.,FAMILY HISTORY: , Nonsignificant.,SURGICAL HISTORY: , Tubal ligation.,MEDICATIONS: , On pain medications, ibuprofen.,ALLERGIES:, SULFA.,PERSONAL HISTORY: , She is a nonsmoker. Does not consume alcohol. No history of recreational drug use.,PAST MEDICAL HISTORY: , History of chest pain in the past. Had workup done including nuclear myocardial perfusion scan, which was reportedly abnormal. Subsequently, the patient underwent cardiac catheterization in 11/07, which was also normal. An echocardiogram at that time was also normal. At this time, presentation with lightheaded, dizziness, and palpitation.,REVIEW OF SYSTEMS:,CONSTITUTIONAL: No history of fever, rigors, or chills.,HEENT: No history of cataract, blurry vision, or glaucoma.,CARDIOVASCULAR: As above.,RESPIRATORY: Shortness of breath. No pneumonia or valley fever.,GASTROINTESTINAL: No epigastric discomfort, hematemesis or melena.,UROLOGICAL: No frequency or urgency.,MUSCULOSKELETAL: Nonsignificant.,NEUROLOGICAL: No TIA. No CVA. No seizure disorder.,ENDOCRINE/HEMATOLOGIC: Nonsignificant.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse of 69, blood pressure 127/75, afebrile, and respiratory rate 16 per minute.,HEENT: Atraumatic and normocephalic.,NECK: Neck veins flat. No carotid bruits. No thyromegaly. No lympyhadenopathy.,LUNGS: Air entry bilaterally fair.,HEART: PMI normal. S1 and S2 regular.,ABDOMEN: Soft and nontender. Bowel sounds present.,EXTREMITIES: No edema. Pulses palpable. No clubbing or cyanosis.,CNS: Benign.,PSYCHOLOGICAL: Normal.,MUSCULOSKELETAL: Nonsignificant.,EKG: , Normal sinus rhythm, incomplete right bundle-branch block.,LABORATORY DATA:, H&H stable. BUN and creatinine within normal limits. Cardiac enzyme profile negative. Chest x-ray unremarkable.,IMPRESSION:,1. Lightheaded, dizziness in a 50-year-old female. No documented arrhythmia with the symptoms of palpitation.,2. Normal cardiac structure by echocardiogram a year and half ago.,3. Normal cardiac catheterization in 11/07.,4. Negative workup so far for acute cardiac event in terms of EKG, cardiac enzyme profile.

Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.

Cardiovascular / Pulmonary

Laryngoscopy

PREOPERATIVE DIAGNOSIS,Subglottic upper tracheal stenosis.,POSTOPERATIVE DIAGNOSIS,Subglottic upper tracheal stenosis.,OPERATION PREFORMED,Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.,INDICATIONS FOR THE SURGERY,The patient is a 76-year-old white female with a history of subglottic upper tracheal stenosis. She has had undergone multiple previous endoscopic procedures in the past; last procedure was in January 2007. She returns with some increasing shortness of breath and dyspnea on exertion. Endoscopic reevaluation is offered to her. The patient has been considering laryngotracheal reconstruction; however, due to a recent death in the family, she has postponed this, but she has been having increasing symptoms. An endoscopic treatment was offered to her. Nature of the proposed procedure including risks and complications involving bleeding, infection, alteration of voice, speech, or swallowing, hoarseness changing permanently, recurrence of stenosis despite a surgical intervention, airway obstruction necessitating a tracheostomy now or in the future, cardiorespiratory, and anesthetic risks were all discussed in length. The patient states she understood and wished to proceed.,DESCRIPTION OF THE OPERATION,The patient was taken to the operating room, placed on table in supine position. Following adequate general anesthesia, the patient was prepared for endoscopy. The top sliding laryngoscope was then inserted in the oral cavity, pharynx, and larynx examined. In the oral cavity, she had good dentition. Tongue and buccal cavity mucosa were without ulcers, masses, or lesions. The oropharynx was clear. The larynx was then manually suspended. Epiglottis area, epiglottic folds, false cords, true vocal folds with some mild edema, but otherwise, without ulcers, masses, or lesions, and the supraglottic and glottic airway were widely patent. The larynx was manually suspended and a 5 x 30 pediatric rigid bronchoscope was passed through the vocal folds. At the base of the subglottis, there was a narrowing and in the upper trachea, restenosis had occurred. Moderate amount of mucoid secretions, these were suctioned, following which the area of stenosis was dilated. Remainder of the bronchi was then examined. The mid and distal trachea were widely patent. Pale pink mucosa takeoff from mainstem bronchi were widely patent without ulcers, lesions, or evidence of scarring. The scope was pulled back and removed and following this, a 6 x 30 pediatric rigid bronchoscope was passed through the larynx and further dilatation carried out. Once this had been completed, dramatic improvement in the subglottic upper tracheal airway accomplished. Instrumentation was removed and a #6 endotracheal tube, uncuffed, was placed to allow smooth emerge from anesthesia. The patient tolerated the procedure well without complication.

cardiovascular / pulmonary, stenosis, epiglottis, subglottic, bronchoscope, bronchoscopy, endoscopic, laryngoscopy, laryngotracheal reconstruction, larynx, oral cavity, pharynx, tracheal, true vocal folds, vocal, upper tracheal stenosis, subglottic upper tracheal, subglottic upper, upper tracheal, airway, cavity, patent,

Laparoscopic lysis of adhesions and Laparoscopic left adrenalectomy. Left adrenal mass, 5.5 cm and intraabdominal adhesions.

Cardiovascular / Pulmonary

Laparoscopic Adrenalectomy

PREOPERATIVE DIAGNOSIS: , Left adrenal mass, 5.5 cm.,POSTOPERATIVE DIAGNOSES:,1. Left adrenal mass, 5.5 cm.,2. Intraabdominal adhesions.,PROCEDURE PERFORMED:,1. Laparoscopic lysis of adhesions.,2. Laparoscopic left adrenalectomy.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS:, Less than 100 cc.,FLUIDS: , 3500 cc crystalloids.,DRAINS:, None.,DISPOSITION:, The patient was taken to recovery room in stable condition. Sponge, needle, and instrument counts were correct per OR staff.,HISTORY:, This is a 57-year-old female who was found to have a large left adrenal mass, approximately 5.5 cm in size. She had undergone workup previously with my associate, Dr. X as well as by Endocrinology, and showed this to be a nonfunctioning mass. Due to the size, the patient was advised to undergo an adrenalectomy and she chose the laparoscopic approach due to her multiple pulmonary comorbidities.,INTRAOPERATIVE FINDINGS: , Showed multiple intraabdominal adhesions in the anterior abdominal wall. The spleen and liver were unremarkable. The gallbladder was surgically absent.,There was large amount of omentum and bowel in the pelvis, therefore the gynecological organs were not visualized. There was no evidence of peritoneal studding or masses. The stomach was well decompressed as well as the bladder.,PROCEDURE DETAILS: , After informed consent was obtained from the patient, she was taken to the operating room and given general anesthesia. She was placed on a bean bag and secured to the table. The table was rotated to the right to allow gravity to aid in our retraction of the bowel.,Prep was performed. Sterile drapes were applied. Using the Hassan technique, we placed a primary laparoscopy port approximately 3 cm lateral to the umbilicus on the left. Laparoscopy was performed with ___________. At this point, we had a second trocar, which was 10 mm to 11 mm port. Using the non-cutting trocar in the anterior axillary line and using Harmonic scalpel, we did massive lysis of adhesions from the anterior abdominal wall from the length of the prior abdominal incision, the entire length of the abdominal incision from the xiphoid process to the umbilicus. The adhesions were taken down off the entire anterior abdominal wall.,At this point, secondary and tertiary ports were placed. We had one near the midline in the subcostal region and to the left midline and one at the midclavicular line, which were also 10 and 11 ports using a non-cutting blade.,At this point, using the Harmonic scalpel, we opened the white line of Toldt on the left and reflected the colon medially, off the anterior aspect of the Gerota's fascia. Blunt and sharp dissection was used to isolate the upper pole of the kidney, taking down some adhesions from the spleen. The colon was further mobilized medially again using gravity to aid in our retraction. After isolating the upper pole of the kidney using blunt and sharp dissection as well as the Harmonic scalpel, we were able to dissect the plane between the upper pole of the kidney and lower aspect of the adrenal gland. We were able to isolate the adrenal vein, dumping into the renal vein, this was doubly clipped and transected. There was also noted to be vascular structure of the upper pole, which was also doubly clipped and transected. Using the Harmonic scalpel, we were able to continue free the remainder of the adrenal glands from its attachments medially, posteriorly, cephalad, and laterally.,At this point, using the EndoCatch bag, we removed the adrenal gland through the primary port in the periumbilical region and sent the flap for analysis. Repeat laparoscopy showed no additional findings. The bowel was unremarkable, no evidence of bowel injury, no evidence of any bleeding from the operative site.,The operative site was irrigated copiously with saline and reinspected and again there was no evidence of bleeding. The abdominal cavity was desufflated and was reinspected. There was no evidence of bleeding.,At this point, the camera was switched to one of the subcostal ports and the primary port in the periumbilical region was closed under direct vision using #0 Vicryl suture. At this point, each of the other ports were removed and then with palpation of each of these ports, this indicated that the non-cutting ports did close and there was no evidence of fascial defects.,At this point, the procedure was terminated. The abdominal cavity was desufflated as stated. The patient was sent to Recovery in stable condition. Postoperative orders were written. The procedure was discussed with the patient's family at length.

Patient with a history of ischemic cardiac disease and hypercholesterolemia.

Cardiovascular / Pulmonary

Ischemic Cardiac Disease - Progress Note

HISTORY OF PRESENT ILLNESS:, The patient is a 68-year-old man who returns for recheck. He has a history of ischemic cardiac disease, he did see Dr. XYZ in February 2004 and had a thallium treadmill test. He did walk for 8 minutes. The scan showed some mild inferior wall scar and ejection fraction was well preserved. He has not had difficulty with chest pain, palpitations, orthopnea, nocturnal dyspnea, or edema.,PAST MEDICAL HISTORY/SURGERIES/HOSPITALIZATIONS: , He had tonsillectomy at the age of 8. He was hospitalized in 1996 with myocardial infarction and subsequently underwent cardiac catheterization and coronary artery bypass grafting procedure. He did have LIMA to the LAD and had three saphenous vein grafts performed otherwise.,MEDICATIONS:, Kerlone 10 mg 1/2 pill daily, gemfibrozil 600 mg twice daily, Crestor 80 mg 1/2 pill daily, aspirin 325 mg daily, vitamin E 400 units daily, and Citrucel one daily.,ALLERGIES: , None known.,FAMILY HISTORY: ,Father died at the age of 84. He had a prior history of cancer of the lung and ischemic cardiac disease. Mother died in her 80s from congestive heart failure. He has two brothers and six sisters living who remain in good health.,PERSONAL HISTORY: ,Quit smoking in 1996. He occasionally drinks alcoholic beverages.,REVIEW OF SYSTEMS:,Endocrine: He has hypercholesterolemia treated with diet and medication. He reports that he did lose 10 pounds this year.,Neurologic: Denies any TIA symptoms.,Genitourinary: He has occasional nocturia. Denies any difficulty emptying his bladder.,Gastrointestinal: He has a history of asymptomatic cholelithiasis.,PHYSICAL EXAMINATION:,Vital Signs: Weight: 225 pounds. Blood pressure: 130/82. Pulse: 83. Temperature: 96.4 degrees.,General Appearance: He is a middle-aged man who is not in any acute distress.,HEENT: Mouth: The posterior pharynx is clear.,Neck: Without adenopathy or thyromegaly.,Chest: Lungs are resonant to percussion. Auscultation reveals normal breath sounds.,Heart: Normal S1, S2, without gallops or rubs.,Abdomen: Without tenderness or masses.,Extremities: Without edema.,IMPRESSION/PLAN:,1. Ischemic cardiac disease. This remains stable. He will continue on the same medication. He reports he has had some laboratory studies today.,2. Hypercholesterolemia. He will continue on the same medication.,3. Facial tic. We also discussed having difficulty with the facial tic at the left orbital region. This occurs mainly when he is under stress. He has apparently had numerous studies in the past and has seen several doctors in Wichita about this. At one time was being considered for some type of operation. His description, however, suggests that they were considering an operation for tic douloureux. He does not have any pain with this tic and this is mainly a muscle spasm that causes his eye to close. Repeat neurology evaluation was advised. He will be scheduled to see Dr. XYZ in Newton on 09/15/2004.,4. Immunization. Addition of pneumococcal vaccination was discussed with him but had been decided by him at the end of the appointment. We will have this discussed with him further when his laboratory results are back.

Specimen - Lung, left lower lobe resection. Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma. The tumor closely approaches the pleural surface but does not invade the pleura.

Cardiovascular / Pulmonary

Immunohistochemical Study

CLINICAL HISTORY: , Patient is a 37-year-old female with a history of colectomy for adenoma. During her preop evaluation it was noted that she had a lesion on her chest x-ray. CT scan of the chest confirmed a left lower mass.,SPECIMEN: , Lung, left lower lobe resection.,IMMUNOHISTOCHEMICAL STUDIES:, Tumor cells show no reactivity with cytokeratin AE1/AE3. No significant reactivity with CAM5.2 and no reactivity with cytokeratin-20 are seen. Tumor cells show partial reactivity with cytokeratin-7. PAS with diastase demonstrates no convincing intracytoplasmic mucin. No neuroendocrine differentiation is demonstrated with synaptophysin and chromogranin stains. Tumor cells show cytoplasmic and nuclear reactivity with S100 antibody. No significant reactivity is demonstrated with melanoma marker HMB-45 or Melan-A. Tumor cell nuclei (spindle cell and pleomorphic/giant cell carcinoma components) show nuclear reactivity with thyroid transcription factor marker (TTF-1). The immunohistochemical studies are consistent with primary lung sarcomatoid carcinoma with pleomorphic/giant cell carcinoma and spindle cell carcinoma components.,FINAL DIAGNOSIS:,Histologic Tumor Type: Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma.,Tumor Size: 2.7 x 2.0 x 1.4 cm.,Visceral Pleura Involvement: The tumor closely approaches the pleural surface but does not invade the pleura.,Vascular Invasion: Present.,Margins: Bronchial resection margins and vascular margins are free of tumor.,Lymph Nodes: Metastatic sarcomatoid carcinoma into one of four hilar lymph nodes.,Pathologic Stage: pT1N1MX.

cardiovascular / pulmonary, cytokeratin-20, hmb-45, melanoma, spindle cell carcinoma, tumor cells, carcinoma, immunohistochemical, lung, cytokeratin, sarcomatoid, spindle, pleural, cell, tumor,

Comprehensive electrophysiology studies with attempted arrhythmia induction and IV Procainamide infusion for Brugada syndrome.

Cardiovascular / Pulmonary

IV Procainamide Infusion

PREOPERATIVE DIAGNOSIS: , Syncopal episodes with injury. See electrophysiology consultation.,POSTOPERATIVE DIAGNOSES:,1. Normal electrophysiologic studies.,2. No inducible arrhythmia.,3. Procainamide infusion negative for Brugada syndrome.,PROCEDURES:,1. Comprehensive electrophysiology studies with attempted arrhythmia induction.,2. IV Procainamide infusion for Brugada syndrome.,DESCRIPTION OF PROCEDURE:, The patient gave informed consent for comprehensive electrophysiologic studies. She received small amounts of intravenous fentanyl and Versed for conscious sedation. Then 1% lidocaine local anesthesia was used. Three catheters were placed via the right femoral vein; 5-French catheters to the right ventricular apex and right atrial appendage; and a 6-French catheter to the His bundle. Later in the procedure, the RV apical catheter was moved to RV outflow tract.,ELECTROPHYSIOLOGICAL FINDINGS:, Conduction intervals in sinus rhythm were normal. Sinus cycle length 768 ms, PA interval 24 ms, AH interval 150 ms, HV interval 46 ms. Sinus node recovery times were also normal at 1114 ms. Corrected sinus node recovery time was normal at 330 ms. One-to-one AV conduction was present to cycle length 480 ms, AH interval 240 ms, HV interval 54 ms. AV nodal effective refractory period was normal, 440 ms at drive cycle length 600 ms. RA-ERP was 250 ms. With ventricular pacing, there was VA disassociation present.,Since there was no evidence for dual AV nodal pathways, and poor retrograde conduction, isoproterenol infusion was not performed to look for SVT.,Programmed ventricular stimulation was performed at both right ventricular apex and right ventricular outflow tracts. Drive cycle length 600, 500, and 400 ms was used with triple extrastimuli down to troubling intervals of 180 ms, or refractoriness. There was no inducible VT. Longest run was 5 beats of polymorphic VT, which is a nonspecific finding. From the apex 400-600 with 2 extrastimuli were delivered, again with no inducible VT.,Procainamide was then infused, 20 mg/kg over 10 minutes. There were no ST segment changes. HV interval after IV Procainamide remained normal at 50 ms.,ASSESSMENT: , Normal electrophysiologic studies. No evidence for sinus node dysfunction or atrioventricular block. No inducible supraventricular tachycardia or ventricular tachycardia, and no evidence for Brugada syndrome.,PLAN: , The patient will follow up with Dr. X. She recently had an ambulatory EEG. I will plan to see her again on a p.r.n. basis should she develop a recurrent syncopal episodes. Reveal event monitor was considered, but not placed since she has only had one single episode.

cardiovascular / pulmonary, arrhythmia, attempted arrhythmia induction, conduction, sinus rhythm, electrophysiologic studies, sinus node, iv procainamide, brugada syndrome, electrophysiology, sinus, ventricular,

Lexiscan Nuclear Myocardial Perfusion Scan. Chest pain. Patient unable to walk on a treadmill. Nondiagnostic Lexiscan. Normal nuclear myocardial perfusion scan.

Cardiovascular / Pulmonary

Lexiscan Nuclear Scan

EXAM:, Lexiscan Nuclear Myocardial Perfusion Scan.,INDICATION:, Chest pain.,TYPE OF TEST: ,Lexiscan, unable to walk on a treadmill.,INTERPRETATION: , Resting heart rate of 96, blood pressure of 141/76. EKG, normal sinus rhythm, nonspecific ST-T changes, left bundle branch block. Post Lexiscan 0.4 mg injected intravenously by standard protocol. Peak heart rate was 105, blood pressure of 135/72. EKG remains the same. No symptoms are noted.,SUMMARY:,1. Nondiagnostic Lexiscan.,2. Nuclear interpretation as below.,NUCLEAR MYOCARDIAL PERFUSION SCAN WITH STANDARD PROTOCOL:, Resting and stress images were obtained with 10.4, 32.5 mCi of tetrofosmin injected intravenously by standard protocol. Myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake. There is no evidence of reversible or fixed defect. Gated SPECT revealed mild global hypokinesis, more pronounced in the septal wall possibly secondary to prior surgery. Ejection fraction calculated at 41%. End-diastolic volume of 115, end-systolic volume of 68.,IMPRESSION:,1. Normal nuclear myocardial perfusion scan.,2. Ejection fraction 41% by gated SPECT.

cardiovascular / pulmonary, lexiscan nuclear myocardial perfusion scan, treadmill, bundle branch block, mci, tetrofosmin, nuclear myocardial perfusion scan, blood pressure, gated spect, ejection fraction, myocardial perfusion, ejection, fraction, myocardial, lexiscan, nuclear,

Nonischemic cardiomyopathy, branch vessel coronary artery disease, congestive heart failure - NYHA Class III, history of nonsustained ventricular tachycardia, hypertension, and hepatitis C.

Cardiovascular / Pulmonary

Hypertension & Cardiomyopathy

PROBLEMS LIST:,1. Nonischemic cardiomyopathy.,2. Branch vessel coronary artery disease.,3. Congestive heart failure, NYHA Class III.,4. History of nonsustained ventricular tachycardia.,5. Hypertension.,6. Hepatitis C.,INTERVAL HISTORY: , The patient was recently hospitalized for CHF exacerbation and was discharged with increased medications. However, he did not fill his prescriptions and came back with persistent shortness of breath on exertion and on rest. He has history of orthopnea and PND. He has gained a few pounds of weight but denied to have any palpitation, presyncope, or syncope.,REVIEW OF SYSTEMS: , Positive for right upper quadrant pain. He has occasional nausea, but no vomiting. His appetite has decreased. No joint pain, TIA, seizure or syncope. Other review of systems is unremarkable.,I reviewed his past medical history, past surgical history, and family history.,SOCIAL HISTORY: , He has quit smoking, but unfortunately was positive for cocaine during last hospital stay in 01/08.,ALLERGIES: , He has no known drug allergies.,MEDICATIONS:, I reviewed his medication list in the chart. He states he is compliant, but he was not taking the revised dose of medications as per discharge orders and prescription.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse 91 per minute and regular, blood pressure 151/102 in the right arm and 152/104 in the left arm, weight 172 pounds, which is about 6 pounds more than last visit in 11/07. HEENT: Atraumatic and normocephalic. No pallor, icterus or cyanosis. NECK: Supple. Jugular venous distention 5 cm above the clavicle present. No thyromegaly. LUNGS: Clear to auscultation. No rales or rhonchi. Pulse ox was 98% on room air. CVS: S1 and S2 present. S3 and S4 present. ABDOMEN: Soft and nontender. Liver is palpable 5 cm below the right subcostal margin. EXTREMITIES: No clubbing or cyanosis. A 1+ edema present.,ASSESSMENT AND PLAN:, The patient has hypertension, nonischemic cardiomyopathy, and branch vessel coronary artery disease. Clinically, he is in NYHA Class III. He has some volume overload and was not unfortunately taking Lasix as prescribed. I have advised him to take Lasix 40 mg p.o. b.i.d. I also increased the dose of hydralazine from 75 mg t.i.d. to 100 mg t.i.d. I advised him to continue to take Toprol and lisinopril. I have also added Aldactone 25 mg p.o. daily for survival advantage. I reinforced the idea of not using cocaine. He states that it was a mistake, may be somebody mixed in his drink, but he has not intentionally taken any cocaine. I encouraged him to find a primary care provider. He will come for a BMP check in one week. I asked him to check his blood pressure and weight. I discussed medication changes and gave him an updated list. I have asked him to see a gastroenterologist for hepatitis C. At this point, his Medicaid is pending. He has no insurance and finds hard to find a primary care provider. I will see him in one month. He will have his fasting lipid profile, AST, and ALT checked in one week.

cardiovascular / pulmonary, congestive heart failure, hypertension, cardiomyopathy, coronary artery disease, ventricular tachycardia, nonischemic cardiomyopathy, branch vessel, nyha class, nonischemic, tachycardia, orthopnea,

An 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation.

Cardiovascular / Pulmonary

Hypertension - Consult

HISTORY OF PRESENT ILLNESS: , The patient is an 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation although not seen recently and I was asked to perform cardiology consultation for her because there was concern for atrial fibrillation after a fall. Basically the patient states that yesterday she fell and she is not certain about the circumstances, on her driveway, and on her left side hit a rock. When she came to the emergency room, she was found to have a rapid atrial tachyarrhythmia, and was put on Cardizem with reportedly heart rate in the 50s, so that was stopped. Review of EKGs from that time shows what appears to be multifocal atrial tachycardia with followup EKG showing wandering atrial pacemaker. An ECG this morning showing normal sinus rhythm with frequent APCs. Her potassium at that time was 3.1. She does recall having palpitations because of the pain after the fall, but she states she is not having them since and has not had them prior. She denies any chest pain nor shortness of breath prior to or since the fall. She states clearly she can walk and she would be able to climb 2 flights of stairs without problems.,PAST CARDIAC HISTORY: , She is followed by Dr. X in our office and has a history of severe tricuspid regurgitation with mild elevation and PA pressure. On 05/12/08, preserved left and right ventricular systolic function, aortic sclerosis with apparent mild aortic stenosis, and bi-atrial enlargement. She has previously had a Persantine Myoview nuclear rest-stress test scan completed at ABCD Medical Center in 07/06 that was negative. She has had significant mitral valve regurgitation in the past being moderate, but on the most recent echocardiogram on 05/12/08, that was not felt to be significant. She has a history of hypertension and EKGs in our office show normal sinus rhythm with frequent APCs versus wandering atrial pacemaker. She does have a history of significant hypertension in the past. She has had dizzy spells and denies clearly any true syncope. She has had bradycardia in the past from beta-blocker therapy.,MEDICATIONS ON ADMISSION:,1. Multivitamin p.o. daily.,2. Aspirin 325 mg once a day.,3. Lisinopril 40 mg once a day.,4. Felodipine 10 mg once a day.,5. Klor-Con 20 mEq p.o. b.i.d.,6. Omeprazole 20 mg p.o. daily presumably for GERD.,7. MiraLax 17 g p.o. daily.,8. Lasix 20 mg p.o. daily.,ALLERGIES: , PENICILLIN. IT IS LISTED THAT TOPROL HAS CAUSED SHORTNESS OF BREATH IN HER OFFICE CHART AND I BELIEVE SHE HAS HAD SIGNIFICANT BRADYCARDIA WITH THAT IN THE PAST.,FAMILY HISTORY:, She states her brother died of an MI suddenly in his 50s.,SOCIAL HISTORY: , She does not smoke cigarettes, abuse alcohol, nor use any illicit drugs. She is retired from Morse Chain and delivering newspapers. She is widowed. She lives alone but has family members who live either on her property or adjacent to it.,REVIEW OF SYSTEMS: , She denies a history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding, stomach ulcers. She does not recall renal calculi, nor cholelithiasis, denies asthma, emphysema, pneumonia, tuberculosis, sleep apnea, home oxygen use. She does note occasional peripheral edema. She is not aware of prior history of MI. She denies diabetes. She does have a history of GERD. She notes feeling depressed at times because of living alone. She denies rheumatologic conditions including psoriasis or lupus. Remainder of review of systems is negative times 15 except as described above.,PHYSICAL EXAM: ,Height 5 feet 0 inches, weight 123 pounds, temperature 99.2 degrees Fahrenheit, blood pressure has ranged from 160/87 with pulses recorded at being 144, and currently ranges 101/53 to 147/71, pulse 64, respiratory rate 20, O2 saturation 97%. On general exam, she is a pleasant elderly woman who is hard of hearing, but is alert and interactive. HEENT: Shows cranium is normocephalic and atraumatic. She has moist mucosal membranes. Neck veins were not distended. There are no carotid bruits. Lungs: Clear to auscultation anteriorly without wheezes. She is relatively immobile because of her left hip fracture. Cardiac Exam: S1, S2, regular rate, frequent ectopic beats, 2/6 systolic ejection murmur, preserved aortic component of the second heart sound. There is also a soft holosystolic murmur heard. There is no rub or gallop. PMI is nondisplaced. Abdomen is soft and nondistended. Bowel sounds present. Extremities without significant clubbing, cyanosis, and there is trivial to 1+ peripheral edema. Pulses appear grossly intact. Affect is appropriate. Visible skin warm and perfused. She is not able to move because of left hip fracture easily in bed.,DIAGNOSTIC STUDIES/LAB DATA: , Pertinent labs include chest x-ray with radiology report pending but shows only a calcified aortic knob. No clear pulmonary vascular congestion. Sodium 140, potassium 3.7, it was 3.1 on admission, chloride 106, bicarbonate 27, BUN 17, creatinine 0.9, glucose 150, magnesium was 2 on 07/13/06. Troponin was 0.03 followed by 0.18. INR is 0.93, white blood cell count 10.2, hematocrit 36, platelet count 115,000.,EKGs are reviewed. Initial EKG done on 08/19/08 at 1832 shows MAT, heart rate of 104 beats per minute, no ischemic changes. She had a followup EKG done at 20:37 on 08/19/08, which shows wandering atrial pacemaker and some lateral T-wave changes, not significantly changed from prior. Followup EKG done this morning shows normal sinus rhythm with frequent APCs.,IMPRESSION: ,She is an 84-year-old female with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension and mild aortic stenosis admitted after a fall with left hip fracture and she will require surgery. Telemetry now reviewed, shows predominantly normal sinus rhythm with frequent APCs _____ earlier yesterday evening showed burst of multifocal atrial tachycardia and I suspect that was exacerbated by prior hypokalemia, which has been corrected. There has been no atrial fibrillation documented. I do not feel these troponins are significant given the stress or fall in prior multifocal atrial tachycardia with increased rate especially in the absence of chest pain or shortness of breath. She actually describes feeling good exercise capacity prior to this fall. Given favorable risk to benefit ratio for needed left hip surgery, I feel she may proceed with needed left hip surgery from a cardiac standpoint with continued verapamil, which has been started, which should help control the multifocal atrial tachycardia, which she had and would watch for heart rate with that. Continued optimization of electrolytes. The patient cannot take beta-blockers as previously Toprol reportedly caused shortness of breath, although, there was some report that it caused bradycardia so we would watch her heart rate on the verapamil. The patient is aware of the cardiac risks, certainly it is moderate, and wishes to proceed with needed surgery. I do not feel any further cardiac evaluation is needed at this time and the patient may followup with Dr. X after discharge. Regarding her mild thrombocytopenia, I would defer that to hospitalist and continue proton pump inhibitors for history of gastroesophageal reflux disease, management of left hip fracture as per orthopedist.

cardiovascular / pulmonary, hypokalemia, shortness of breath, atrial tachycardia, sinus rhythm, hip fracture, atrial, tachycardia, rhythm, apcs, cardiac, regurgitation, aortic, hypertension, pulmonary,

Patient with hypertension, syncope, and spinal stenosis - for recheck.

Cardiovascular / Pulmonary

Hypertension - Progress Note

SUBJECTIVE:, The patient is a 78-year-old female who returns for recheck. She has hypertension. She denies difficulty with chest pain, palpations, orthopnea, nocturnal dyspnea, or edema.,PAST MEDICAL HISTORY / SURGERY / HOSPITALIZATIONS:, Reviewed and unchanged from the dictation on 12/03/2003.,MEDICATIONS: ,Atenolol 50 mg daily, Premarin 0.625 mg daily, calcium with vitamin D two to three pills daily, multivitamin daily, aspirin as needed, and TriViFlor 25 mg two pills daily. She also has Elocon cream 0.1% and Synalar cream 0.01% that she uses as needed for rash.,ALLERGIES: ,Benadryl, phenobarbitone, morphine, Lasix, and latex.,FAMILY HISTORY / PERSONAL HISTORY: , Reviewed. Mother died from congestive heart failure. Father died from myocardial infarction at the age of 56. Family history is positive for ischemic cardiac disease. Brother died from lymphoma. She has one brother living who has had angioplasties x 2. She has one brother with asthma.,PERSONAL HISTORY:, Negative for use of alcohol or tobacco.,REVIEW OF SYSTEMS:,Bones and Joints: She has had continued difficulty with lower back pain particularly with standing which usually radiates down her right leg. She had been followed by Dr. Mills, but decided to see Dr. XYZ who referred to her Dr Isaac. She underwent several tests. She did have magnetic resonance angiography of the lower extremities and the aorta which were normal. She had nerve conduction study that showed several peripheral polyneuropathy. She reports that she has myelogram last week but has not got results of this. She reports that the rest of her tests have been normal, but it seems that vertebrae shift when she stands and then pinches the nerve. She is now seeing Dr. XYZ who comes to Hutchison from KU Medical Center, and she thinks that she probably will have surgery in the near future.,Genitourinary: She has occasional nocturia.,PHYSICAL EXAMINATION:,Vital Signs: Weight: 227.2 pounds. Blood pressure: 144/72. Pulse: 80. Temperature: 97.5 degrees.,General Appearance: She is an elderly female patient who is not in acute distress.,Mouth: Posterior pharynx is clear.,Neck: Without adenopathy or thyromegaly.,Chest: Lungs are resonant to percussion. Auscultation reveals normal breath sounds.,Heart: Normal S1 and S2 without gallops or rubs.,Abdomen: Without masses or tenderness to palpation.,Extremities: Without edema.,IMPRESSION/PLAN:,1. Hypertension. She is advised to continue with the same medication.,2. Syncope. She previously had an episode of syncope around Thanksgiving. She has not had a recurrence of this and her prior cardiac studies did not show arrhythmias.,3. Spinal stenosis. She still is being evaluated for this and possibly will have surgery in the near future.

cardiovascular / pulmonary, progress note, hypertension, spinal stenosis, syncope, spinal, stenosis, infarction, orthopnea,

Holter monitor report. Predominant rhythm is sinus. Triplet maximum rate of 178 beats per minute noted.

Cardiovascular / Pulmonary

Holter Monitor Report - 1

INDICATIONS: , Predominant rhythm is sinus. Heart rate varied between 56-128 beats per minute, average heart rate of 75 beats per minute. Minimum heart rate of 50 beats per minute.,640 ventricular ectopic isolated beats noted. Rare isolated APCs and supraventricular couplets.,One supraventricular triplet reported.,Triplet maximum rate of 178 beats per minute noted.

cardiovascular / pulmonary, holter monitor, heart rate, supraventricular, triplet, heart, beatsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

Holter monitoring for syncope. Analyzed for approximately 23 hours 57 minutes and artefact noted for approximately 23 seconds.

Cardiovascular / Pulmonary

Holter Monitor Report - 2

INDICATION: , Syncope.,HOLTER MONITOR SUMMARY ANALYSIS: , Analyzed for approximately 23 hours 57 minutes and artefact noted for approximately 23 seconds. Total beats of 108,489, heart rate minimum of approximately 54 beats per minutes at 7 a.m. and maximum of 106 beats per minute at approximately 4 p.m. Average heart rate is approximately 75 beats per minute, total of 31 to bradycardia, longest being 225 beats at approximately 7 in the morning, minimum rate of 43 beats per minute at approximately 01:40 a.m. Total ventricular events of 64, primarily premature ventricular contraction and supraventricular events total beats of 9 atrial premature contractions. No significant ST elevation noted and ST depression noted only in one channel for approximately three minutes for a maximum of 2.7 mm.,IMPRESSION OF THE FINDINGS: , Predominant sinus rhythm with occasional premature ventricular contraction, occasional atrial premature contractions and Mobitz type 1 Wenckebach, several episodes, Mobitz type II, 3 to 2 AV conduction disease noted as well approximately two episodes and one episode of atrial bigeminy noted. No significant pauses noted.

cardiovascular / pulmonary, artefact, ventricular contraction, holter monitor, premature contractions, mobitz type, holter, beatsNOTE

Placement of a subclavian single-lumen tunneled Hickman central venous catheter. Surgeon-interpreted fluoroscopy.

Cardiovascular / Pulmonary

Hickman Central Venous Catheter Placement

PROCEDURE PERFORMED,1. Placement of a subclavian single-lumen tunneled Hickman central venous catheter.,2. Surgeon-interpreted fluoroscopy.,OPERATION IN DETAIL:, After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and anesthesia was administered. Next, a #18-gauge needle was used to locate the subclavian vein. After aspiration of venous blood, a J wire was inserted through the needle using Seldinger technique. The needle was withdrawn. The distal tip location of the J wire was confirmed to be in adequate position with surgeon-interpreted fluoroscopy. Next, a separate stab incision was made approximately 3 fingerbreadths below the wire exit site. A subcutaneous tunnel was created, and the distal tip of the Hickman catheter was pulled through the tunnel to the level of the cuff. The catheter was cut to the appropriate length. A dilator and sheath were passed over the J wire. The dilator and J wire were removed, and the distal tip of the Hickman catheter was threaded through the sheath, which was simultaneously withdrawn. The catheter was flushed and aspirated without difficulty. The distal tip was confirmed to be in good location with surgeon-interpreted fluoroscopy. A 2-0 nylon was used to secure the cuff down to the catheter at the skin level. The skin stab site was closed with a 4-0 Monocryl. The instrument and sponge count was correct at the end of the case. The patient tolerated the procedure well and was transferred to the postanesthesia recovery area in good condition.

cardiovascular / pulmonary, j wire, distal tip, stab incision, tunneled, hickman central venous catheter, subclavian, venous, fluoroscopy, hickman, catheterNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

Holter monitoring - For bradycardia and dizziness.

Cardiovascular / Pulmonary

Holter Monitoring

INDICATION: , Bradycardia and dizziness.,COMMENTS:,1. The patient was monitored for 24 hours.,2. The predominant rhythm was normal sinus rhythm with a minimum heart rate of 56 beats per minute and the maximum heart rate of 114 beats per minute and a mean heart rate of 86 beats per minute.,3. There were occasional premature atrial contractions seen, no supraventricular tachycardia was seen.,4. There was a frequent premature ventricular contraction seen. Between 11:00 a.m. and 11:15 a.m. the patient was in ventricular bigemini and trigemini most of the time. During rest of the monitoring period, there were just occasional premature ventricular contractions seen. No ventricular tachycardia was seen.,5. There were no pathological pauses noted.,6. The longest RR interval was 1.1 second.,7. There were no symptoms reported.

cardiovascular / pulmonary, holter monitoring, bradycardia, bigemini, dizziness, heart rate, interval, predominant, premature, premature ventricular contraction, rhythm, sinus, trigemini, ventricular, bradycardia and dizziness, premature ventricular, monitoring,

Holter Monitor Report

Cardiovascular / Pulmonary

Holter Monitor Report

INTERPRETATION:,1. Predominant rhythm is normal sinus rhythm.,2. No supraventricular arrhythmia.,3. Frequent premature ventricular contractions.,4. Trigemini and couplets.,5. No high-grade atrial ventricular block was noted.,6. Diary was not kept.,IMPRESSION:, Frequent premature atrial contractions, couplets, and trigemini.,

cardiovascular / pulmonary, atrial ventricular block, holter monitor report, holter monitor, frequent premature, holter, monitor, rhythm, ventricular, contractions, trigemini, atrial,

Left heart catheterization, coronary angiography, and left ventriculogram. No angiographic evidence of coronary artery disease. Normal left ventricular systolic function. Normal left ventricular end diastolic pressure.

Cardiovascular / Pulmonary

Heart Catheterization, Ventriculography, & Angiography - 8

PROCEDURES,1. Left heart catheterization.,2. Coronary angiography.,3. Left ventriculogram.,PREPROCEDURE DIAGNOSIS:, Atypical chest pain.,POSTPROCEDURE DIAGNOSES,1. No angiographic evidence of coronary artery disease.,2. Normal left ventricular systolic function.,3. Normal left ventricular end diastolic pressure.,INDICATION: ,The patient is a 58-year-old male with past medical history significant for polysubstance abuse, chronic tobacco abuse, chronic alcohol dependence with withdrawal, atrial flutter, history of ventricular tachycardia with AICD placement, and hepatitis C. The patient was admitted for atypical chest pain and scheduled for cardiac catheterization.,PROCEDURE IN DETAIL:, After informed consent was signed by the patient, the patient was taken to the cardiac catheterization laboratory. He was prepped and draped in the usual sterile manner. The right inguinal area was anesthetized with 2% Xylocaine. A 4-French sheath was inserted into the right femoral artery using the modified Seldinger technique. JL4 and 3DRC catheters were used to cannulate the left and right coronary arteries respectively. Coronary angiographies were performed. These catheters were removed and exchanged for a 4-French pigtail catheter, which was positioned into the left ventricle. Left ventriculography was performed. The patient tolerated the procedure well. At the end of the procedure, all catheters and sheaths were removed. The patient was then transferred to telemetry in a stable condition.,HEMODYNAMIC DATA: , Hemodynamic data shows aortic pressures of 100/56 with mean of 70 mmHg and the LV 100/0 with LVEDP of 10 mmHg.,AORTIC VALVE: ,There is no significant gradient across this valve noted.,LV GRAM: , A 10 mL of contrast were delivered for 3 seconds for a total of 30 mL. Ejection fraction was calculated to be 69%. There were no wall motion abnormalities noted.,ANGIOGRAM,LEFT MAIN CORONARY ARTERY: , Left main coronary artery is a moderate-caliber vessel free of disease and trifurcates.,LAD: , LAD is a long, tortuous vessel which wraps around the apex. The LAD is small in caliber. In addition, there is a long bifurcating small-caliber diagonal branch noted. LAD and its branches are free of disease.,RAMUS INTERMEDIUS: , Ramus intermedius is a long small-caliber vessel free of disease.,LCX: , LCX is a nondominant small-caliber vessel with long bifurcating small-caliber distal OM branch. LCX and its branches are free of disease.,RCA:, RCA is a dominant small-caliber vessel with long small-caliber PDA branch. RCA and its branches are free of disease.,IMPRESSION,1. No angiographic evidence of coronary artery disease.,2. Normal left ventricular systolic function.,3. Normal left ventricular end diastolic pressure.,RECOMMENDATION: , Recommend to look for alternative causes of chest pain.

Left heart catheterization, coronary angiography, left ventriculography. Severe complex left anterior descending and distal circumflex disease with borderline, probably moderate narrowing of a large obtuse marginal branch.

Cardiovascular / Pulmonary

Heart Catheterization, Ventriculography, & Angiography - 7

PROCEDURE: , Left heart catheterization, coronary angiography, left ventriculography.,COMPLICATIONS: , None.,PROCEDURE DETAIL: , The right femoral area was draped and prepped in the usual fashion after Xylocaine infiltration. A 6-French arterial sheath was placed in the usual fashion. Left and right coronary angiograms were then performed in various projections after heparin was given 2000 units intraaortic. The right coronary artery was difficult to cannulate because of its high anterior takeoff. This was nondominant. Several catheters were used. Ultimately, an AL1 diagnostic catheter was used. A pigtail catheter was advanced across the aortic valve. Left ventriculogram was then done in the RAO view using 30 mL of contrast. Pullback gradient was obtained across the aortic valve. Femoral angiogram was performed through the sheath which was above the bifurcation, was removed with a Perclose device with good results. There were no complications. He tolerated this procedure well and returned to his room in good condition.,FINDINGS,1. Right coronary artery: This has an unusual high anterior takeoff. The vessel is nondominant, has diffuse mild-to-moderate disease.,2. Left main trunk: A 30% to 40% distal narrowing is present.,3. Left anterior descending: Just at the ostium of the vessel and up to and including the bifurcation of the first large diagonal branch, there is 80 to 90% narrowing. The diagonal is a large vessel about 3 mm in size.,4. Circumflex: Dominant vessel, 50% narrowing at the origin of the obtuse marginal. After this, there is 40% narrowing in the AV trunk. The small posterior lateral branch has diffuse mild disease and then the vessel gives rise to a fairly large posterior ventricular branch, which has 70% ostial narrowing, and then after this the posterior descending has 80% narrowing at its origin.,5. Left ventriculogram: Normal volume in diastole and systole. Normal systolic function is present. There is no mitral insufficiency or left ventricular outflow obstruction.,DIAGNOSES,1. Severe complex left anterior descending and distal circumflex disease with borderline, probably moderate narrowing of a large obtuse marginal branch. Dominant circumflex system. Severe disease of the posterior descending. Mild left main trunk disease.,2. Normal left ventricular systolic function.,Given the complex anatomy of the predominant problem which is the left anterior descending; given its ostial stenosis and involvement of the bifurcation of the diagonal, would recommend coronary bypass surgery. The patient also has severe disease of the circumflex which is dominant. This anatomy is not appropriate for percutaneous intervention. The case will be reviewed with a cardiac surgeon.

cardiovascular / pulmonary, heart catheterization, coronary angiography, left ventriculography, arterial sheath, coronary artery, obtuse marginal branch, angiography, catheterization,

Very high PT-INR. she came in with pneumonia and CHF. She was noticed to be in atrial fibrillation, which is a chronic problem for her.

Cardiovascular / Pulmonary

High PT-INR - ER Visit

REASON FOR THE VISIT:, Very high PT/INR.,HISTORY: , The patient is an 81-year-old lady whom I met last month when she came in with pneumonia and CHF. She was noticed to be in atrial fibrillation, which is a chronic problem for her. She did not want to have Coumadin started because she said that she has had it before and the INR has had been very difficult to regulate to the point that it was dangerous, but I convinced her to restart the Coumadin again. I gave her the Coumadin as an outpatient and then the INR was found to be 12. So, I told her to come to the emergency room to get vitamin K to reverse the anticoagulation.,PAST MEDICAL HISTORY:,1. Congestive heart failure.,2. Renal insufficiency.,3. Coronary artery disease.,4. Atrial fibrillation.,5. COPD.,6. Recent pneumonia.,7. Bladder cancer.,8. History of ruptured colon.,9. Myocardial infarction.,10. Hernia repair.,11. Colon resection.,12. Carpal tunnel repair.,13. Knee surgery.,MEDICATIONS:,1. Coumadin.,2. Simvastatin.,3. Nitrofurantoin.,4. Celebrex.,5. Digoxin.,6. Levothyroxine.,7. Vicodin.,8. Triamterene and hydrochlorothiazide.,9. Carvedilol.,SOCIAL HISTORY: ,She does not smoke and she does not drink.,PHYSICAL EXAMINATION:,GENERAL: Lady in no distress.,VITAL SIGNS: Blood pressure 100/46, pulse of 75, respirations 12, and temperature 98.2.,HEENT: Head is normal.,NECK: Supple.,LUNGS: Clear to auscultation and percussion.,HEART: No S3, no S4, and no murmurs.,ABDOMEN: Soft.,EXTREMITIES: Lower extremities, no edema.,ASSESSMENT:,1. Atrial fibrillation.,2. Coagulopathy, induced by Coumadin.,PLAN: , Her INR at the office was 12. I will repeat it, and if it is still elevated, I will give vitamin K 10 mg in 100 mL of D5W and then send her home and repeat the PT/INR next week. I believe at this time that it is too risky to use Coumadin in her case because of her age and comorbidities, the multiple medications that she takes and it is very difficult to keep an adequate level of anticoagulation that is safe for her. She is prone to a fall and this would be a big problem. We will use one aspirin a day instead of the anticoagulation. She is aware of the risk of stroke, but she is very scared of the anticoagulation with Coumadin and does not want to use the Coumadin at this time and I understand. We will see her as an outpatient.

Left heart catheterization with left ventriculography and selective coronary angiography. A 50% distal left main and two-vessel coronary artery disease with normal left ventricular systolic function. Frequent PVCs. Metabolic syndrome.

Cardiovascular / Pulmonary

Heart Catheterization, Ventriculography, & Angiography - 6

PREOPERATIVE DIAGNOSES,1. Dyspnea on exertion with abnormal stress echocardiography.,2. Frequent PVCs.,3. Metabolic syndrome.,POSTOPERATIVE DIAGNOSES,1. A 50% distal left main and two-vessel coronary artery disease with normal left ventricular systolic function.,2. Frequent PVCs.,3. Metabolic syndrome.,PROCEDURES,1. Left heart catheterization with left ventriculography.,2. Selective coronary angiography.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was brought to the Cardiac Catheterization Laboratory in fasting state. Both groins were prepped and draped in the usual sterile fashion. Xylocaine 1% was used as local anesthetic. Versed and fentanyl were used for conscious sedation. Next, a #6-French sheath was placed in the right femoral artery using modified Seldinger technique. Next, selective angiography of the left coronary artery was performed in multiple views using #6-French JL4 catheter. Next, selective angiography of the right coronary artery was performed in multiple views using #6-French 3DRC catheter. Next, a #6-French angle pigtail catheter was advanced into the left ventricle. The left ventricular pressure was then recorded. Left ventriculography was the performed using 36 mL of contrast injected over 3 seconds. The left heart pull back was then performed. The catheter was then removed.,Angiography of the right femoral artery was performed. Hemostasis was obtained by Angio-Seal closure device. The patient left the Cardiac Catheterization Laboratory in stable condition.,HEMODYNAMICS,1. LV pressure was 163/0 with end-diastolic pressure of 17. There was no significant gradient across the aortic valve.,2. Left ventriculography showed old inferior wall hypokinesis. Global left ventricular systolic function is normal. Estimated ejection fraction was 58%. There is no significant mitral regurgitation.,3. Significant coronary artery disease.,4. The left main is approximately 7 or 8 mm proximally. It trifurcates into left anterior descending artery, ramus intermedius artery, and left circumflex artery. The distal portion of the left main has an ulcerated excentric plaque, up to about 50% in severity.,5. The left anterior descending artery is around 4 mm proximally. It extends slightly beyond the apex into the inferior wall. It gives rises to several medium size diagonal branches as well as small to medium size multiple septal perforators. At the ostium of the left anterior descending artery, there was an eccentric plaque up to 70% to 80%, best seen in the shallow LAO with caudal angulation.,There was no other flow-limiting disease noted in the rest of the left anterior descending artery or its major branches.,The ramus intermedius artery is around 3 mm proximally, but shortly after its origin, it bifurcates into two medium size branches. There was no significant disease noted in the ramus intermedius artery however.,The left circumflex artery is around 2.5 mm proximally. It gave off a recurrent atrial branch and a small AV groove branch prior to terminating into a bifurcating medium size obtuse marginal branch. The mid to distal circumflex has a moderate disease, which is relatively diffuse up to about 40% to 50%.,The right coronary artery is around 4 mm in diameter. It gives off conus branch, two medium size acute marginal branches, relatively large posterior descending artery and a posterior lateral branch. In the mid portion of the right coronary artery at the origin of the first acute marginal branch, there is a relatively discrete stenosis of about 80% to 90%. Proximally, there is an area of eccentric plaque, but seem to be non-flow limiting, at best around 20% to 30%. Additionally, there is what appears to be like a shell-like lesion in the proximal segment of the right coronary artery as well. The posterior descending artery has an eccentric plaque of about 40% to 50% in its mid segment.,PLAN: ,Plan to consult cardiovascular surgery for consideration of coronary artery bypass surgery. Continue risk factor modification, aspirin, and beta blocker.

cardiovascular / pulmonary, heart catheterization, ventriculography, coronary angiography, dyspnea, metabolic syndrome, two-vessel coronary artery disease, echocardiography, selective coronary angiography, anterior descending artery, branches, coronary, angiography, artery, catheterization,

Left heart catheterization, left ventriculography, selective coronary angiography.

Cardiovascular / Pulmonary

Heart Catheterization, Ventriculography, & Angiography - 9

PROCEDURE:, Left heart catheterization, left ventriculography, selective coronary angiography.,INDICATION: , This lady with a previous left internal mammary graft to left anterior descending, saphenous vein graft to obtuse margin branch, saphenous vein graft to the diagonal branch, and saphenous vein graft to the right coronary artery presented with recurrent difficulties with breathing. This was felt to be related largely to chronic obstructive lung disease. She had dynamic T-wave changes in precordial leads. Cardiac enzymes were indeterminate. She was evaluated by Dr. X and given her previous history and multiple risk factors it was elected to proceed with cardiac catheterization and coronary angiography.,Risks of the procedure including risks of conscious sedation, death, cerebrovascular accident, dye reaction, need for emergency surgery, vascular access injury and/or infection, and risks of cath-based interventions were discussed in detail. The patient understood and agreed to proceed.,DESCRIPTION OF THE PROCEDURE: , The patient was brought to the cardiac catheterization laboratory. Under Versed and fentanyl sedation, the right groin was sterilely prepped and draped. Local anesthesia was obtained with 2% Xylocaine. The right femoral artery was entered using modified Seldinger technique and a 4-French introducer sheath placed in that vessel. Through the indwelling femoral arterial sheath, a JL4 4-French catheter was advanced over the wire to the ascending aorta, appropriately aspirated and flushed. Ascending aortic root pressures obtained. This catheter was utilized in an attempt to cannulate the left coronary ostium. This catheter was too small, was exchanged for a JL5 4-French catheter, which was advanced over the wire to the ascending aorta, the cath appropriately aspirated and flushed, and advanced to left coronary ostium and multiple views of left coronary artery obtained.,This catheter was then exchanged for a 4-French right coronary catheter, which was advanced over the wire to the ascending aorta. The catheter appropriately aspirated and flushed. The catheter was advanced in the right coronary artery. Multiple views of that vessel were obtained. The catheter was then sequentially advanced to the saphenous vein graft to the diagonal branch, saphenous vein graft to the obtuse marginal branch, and left internal mammary artery, left anterior descending coronary artery, and multiple views of those vessels were obtained. This catheter was then exchanged for a 4-French pigtail catheter, which was advanced over the wire to the ascending aorta. The catheter was appropriately aspirated and flushed and advanced to left ventricle, baseline left ventricular pressures obtained.,Following this, left ventriculography was performed in a 30-degree RAO projection using 30 mL of contrast injected over 3 seconds. Post left ventriculography pressures were then obtained as was a pullback pressure across the aortic valve. Videotapes were then reviewed. It was elected to terminate the procedure at that point in time.,The vascular sheath was removed and manual compression carried out. Excellent hemostasis was obtained. The patient tolerated the procedure without complication.,RESULTS OF PROCEDURE,1. ,HEMODYNAMICS:, Left ventricular end-diastolic filling pressure was 24. There was no gradient across the aortic valve.,2. ,LEFT VENTRICULOGRAPHY: , Left ventriculography demonstrated well-preserved left ventricular systolic function. Mild inferobasilar hypokinesis was noted. No significant mitral regurgitation noted. Ejection fraction was estimated at 60%.,3. ,CORONARY ARTERIOGRAPHY,A. ,LEFT MAIN CORONARY: , The left main coronary was patent.,B. ,LEFT ANTERIOR DESCENDING CORONARY ARTERY:, Left anterior descending coronary was occluded shortly after a very small first septal perforator was given.,C. ,CIRCUMFLEX CORONARY ARTERY:, Circumflex coronary artery was occluded at its origin.,D. ,RIGHT CORONARY ARTERY,. Right coronary artery was occluded in its mid portion.,4. ,SAPHENOUS VEIN GRAFT ANGIOGRAPHY,A. ,SAPHENOUS VEIN GRAFT TO THE DIAGONAL BRANCH: , The saphenous vein graft to diagonal branch was widely patent at its origin and insertion sites. Excellent flow was noted in the diagonal system with some retrograde flow.,B. There was retrograde flow as well in the left anterior descending system.,C. ,SAPHENOUS VEIN GRAFT TO THE OBTUSE MARGINAL SYSTEM:, Saphenous vein graft to the obtuse marginal system was widely patent at its origin and insertion sites. There was no graft disease noted. Excellent flow was noted in the bifurcating marginal system.,D. ,SAPHENOUS VEIN GRAFT TO RIGHT CORONARY ARTERY:, Saphenous vein graft to right coronary was widely patent with no graft disease. Origin and insertion sites were free of disease. Distal flow in the graft to the posterior descending was normal.,5. ,LEFT INTERNAL MAMMARY ARTERY ANGIOGRAPHY: , Left internal mammary artery angiography demonstrated a widely patent left internal mammary at its origin and insertion sites. There was no focal disease noted, inserted into the mid-to-distal LAD which was a small-caliber vessel. Retrograde filling of a small septal system was noted.,SUMMARY OF RESULTS,1. Elevated left ventricular end-diastolic filling pressure with normal left ventricular systolic function and mild hypokinesis of inferobasilar segment.

Left heart catheterization, selective bilateral coronary angiography and left ventriculography. Revascularization of the left anterior descending with angioplasty and implantation of a drug-eluting stent. Right heart catheterization and Swan-Ganz catheter placement for monitoring.

Cardiovascular / Pulmonary

Heart Catheterization, Ventriculography, & Angiography - 5

PREOPERATIVE DIAGNOSES,1. Acute coronary artery syndrome with ST segment elevation in anterior wall distribution.,2. Documented coronary artery disease with previous angioplasty and stent in the left anterior descending artery and circumflex artery, last procedure in 2005.,3. Primary malignant ventricular arrhythmia and necessitated ventricular fibrillation. He is intubated and ventilated.,POSTOPERATIVE DIAGNOSES:, Acute coronary artery syndrome with ST segment elevation in anterior wall distribution. Primary ventricular arrhythmia. Occluded left anterior descending artery, successfully re-canalized with angioplasty and implantation of the drug-eluting stent. Previously stented circumflex with mild stenosis and previously documented occlusion of the right coronary artery, well collateralized.,PROCEDURES:, Left heart catheterization, selective bilateral coronary angiography and left ventriculography. Revascularization of the left anterior descending with angioplasty and implantation of a drug-eluting stent. Right heart catheterization and Swan-Ganz catheter placement for monitoring.,DESCRIPTION OF PROCEDURE: ,The patient arrived from the emergency room intubated and ventilated. He is hemodynamically stable on heparin and Integrilin bolus and infusion was initiated. The right femoral area was prepped and draped in usual sterile fashion. Lidocaine 2 mL was then filled locally. The right femoral artery was cannulated with an 18-guage needle followed by a 6-French vascular sheath. A guiding catheter XB 3.5 was advanced in manipulated to cannulate the left coronary artery and angiography was obtained. A confirmed occlusion of the left anterior descending artery with minimal collaterals and also occlusion of the right coronary artery, which is well collateralized. An angioplasty wire with present wire was advanced into the left anterior descending artery, and could cross the area of occlusion within the stent. An angioplasty balloon measuring 2.0 x 15 was advanced and three inflations were obtained. It successfully re-canalized the artery. There is evidence of residual stenosis within the distal aspect of the previous stents. A drug-eluting stent Xience 2.75 x 15 was advanced and positioned within the area of stenosis with its distal marker adjacent to bifurcation with a diagonal branch and was deployed at 12 and 18 atmospheres. The intermittent result was improved. An additional inflation was obtained more proximally. His blood pressure fluctuated and dropped in the 70s, correlating with additional sedation. There is patency of the left anterior descending artery and good antegrade flow. The guiding catheter was replaced with a 5-French Judkins right catheter manipulated to cannulate the right coronary artery and selective angiography was obtained. The catheter was then advanced into the left ventricle and pressure measurement was obtained including pullback across the aortic valve. The right femoral vein was cannulated with an 18-guage needle followed by an 8-French vascular sheath. A 8-French Swan-Ganz catheter was then advanced under fluoroscopic and hemodynamic control and pressure stenting was obtained from the right ventricle, pulmonary artery, and pulmonary capillary wedge position. Cardiac catheter was determined by thermal dilution. The procedure was then concluded, well tolerated and without complications. The vascular sheath was in secured in place and the patient return to the coronary care unit for further monitoring. Fluoroscopy time was 8.2 minutes. Total amount of contrast was 113 mL.,HEMODYNAMICS:, The patient remained in sinus rhythm with intermittent ventricular bigeminy post revascularization. His initial blood pressure was 96/70 with a mean of 83 and the left ventricular pressure was 17 mmHg. There was no gradient across the aortic valve. Closing pressure was 97/68 with a mean of 82.,Right heart catheterization with right atrial pressure at 13, right ventricle 31/9, pulmonary artery 33/19 with a mean of 25, and capillary wedge pressure of 19. Cardiac output was 5.87 by thermal dilution.,CORONARIES:, On fluoroscopy, there was evidence of previous coronary stent in the left anterior descending artery and circumflex distribution.,A. Left main coronary: The left main coronary artery is of good caliber and has no evidence of obstructive lesions.,B. Left anterior descending artery: The left anterior descending artery was initially occluded within the previously stented proximal-to-mid segment. There is minimal collateral flow.,C. Circumflex: Circumflex is a nondominant circulation. It supplies a first obtuse marginal branch on good caliber. There is an outline of the stent in the midportion, which has mild 30% stenosis. The rest of the vessel has no significant obstructive lesions. It also supplies significant collaterals supplying the occluded right coronary artery.,D. Right coronary artery: The right coronary artery is a weekly dominant circulation. The vessel is occluded in intermittent portion and has a minimal collateral flow distally.,ANGIOPLASTY: , The left anterior descending artery was the site of re-canalization by angioplasty and implantation of a drug-eluting stent (Xience 15 mm length deployed at 2.9 mm) final result is good with patency of the left anterior descending artery, good antegrade flow and no evidence of dissection. The stent was deployed proximal to the bifurcation with a second diagonal branch, which has remained patent. There is a septal branch overlapped by the stent, which is also patent, although presenting a proximal stenosis. The distal left anterior descending artery trifurcates with two diagonal branches and apical left anterior descending artery. There is good antegrade flow and no evidence of distal embolization.,CONCLUSION: , Acute coronary artery syndrome with ST-segment elevation in anterior wall distribution, complicated with primary ventricular malignant arrhythmia and required defibrillation along intubation and ventilatory support.,Previously documented coronary artery disease with remote angioplasty and stents in the left anterior descending artery and circumflex artery.,Acute coronary artery syndrome with ST-segment elevation in anterior wall distribution related to in-stent thrombosis of the left anterior descending artery, successfully re-canalized with angioplasty and a drug-eluting stent. There is mild-to-moderate disease of the previously stented circumflex and clinic occlusion of the right coronary artery, well collateralized.,Right femoral arterial and venous vascular access.,RECOMMENDATION:, Integrilin infusion is maintained until tomorrow. He received aspirin and Plavix per nasogastric tube. Titrated doses of beta-blockers and ACE inhibitors are initiated. Additional revascularization therapy will be adjusted according to the clinical evaluation.

cardiovascular / pulmonary, ventricular arrhythmia, coronary artery syndrome, st segment elevation, heart catheterization, selective bilateral coronary angiography, ventriculography, catheterization, swan-ganz catheter, anterior descending artery, drug eluting stent, coronary artery, angioplasty, stent, coronary, anterior, angiography, artery, heart,

Left heart catheterization, left ventriculography, selective coronary angiography, and right femoral artery approach.

Cardiovascular / Pulmonary

Heart Catheterization, Ventriculography, & Angiography - 12

PROCEDURE: , Cardiac catheterization by:,a. Left heart catheterization.,b. Left ventriculography.,c. Selective coronary angiography.,d. Right femoral artery approach.,COMPLICATIONS:, None.,MEDICATIONS,1. IV Versed.,2. IV fentanyl.,3. Intravenous fluid administration.,4. Heparin 3000 units IV.,INDICATIONS: , This 70-year-old Asian-American presents with chest pain syndrome, abnormal EKG suggesting an acute ST elevation, anterior myocardial infarction, being taken urgently to cardiac catheterization laboratory with possible coronary intervention.,NARRATIVE: , After detailed informed consent had been obtained. Usual benefits, alternatives, and risks of the procedure had been discussed with the patient, she was agreeable to proceed. The patient was prepped, draped, and anesthetized in the usual manner. Using modified Seldinger technique a 6 French introducer sheath inserted into the right femoral artery. Next, 6 French 3D right coronary catheter was inserted and right coronary angiogram was obtained in various projections. Next, a 6 French JL4.0 left coronary catheter was inserted and left coronary angiogram was obtained in various projections. Next, 4 French pigtail catheter was inserted into left ventricle under fluoroscopic guidance. Left ventricular angiogram was performed. Pre and post angiogram LVEDP, LV, and aortic pressures were obtained. At the end of the procedure catheters were removed and the introducer sheath was secured. The patient was admitted to the TCU in stable condition.,FINDINGS,HEMODYNAMICS,LEFT HEART PRESSURES:, LVEDP of 5, left ventricular systolic pressure of 81, central aortic pressure systolic 70, diastolic 20.,LEFT VENTRICULOGRAPHY: , Left ventricular chamber size is normal. The distal half of the anterior wall of the entire apex and the distal half of the inferior wall are completely akinetic with hypercontractility of the basilar segments of the anterior and inferior wall. Calculated ejection fraction of 51%, which probably overestimates the overall effective ejection fraction. No LV thrombus or mitral regurgitation present.,CORONARY ARTERIOGRAPHY,1. ,RIGHT CORONARY ARTERY: , The RCA gives rise to a posterior descending artery and a small posterolateral branch. Angiographically the right coronary artery is normal.,2. ,LEFT MAIN ARTERY:, The left main vessel is angiographically normal, bifurcates into left anterior descending artery and circumflex system.,3. ,LEFT ANTERIOR DESCENDING ARTERY: , The LAD gives rise to a normal complement of septal branches, diagonal branches, and extends around the apex. Angiographically the mid left anterior descending artery and distal left anterior descending artery demonstrates systolic compression of the vessel lumen, consistent with myocardial bridging. The degree of myocardial bridging appears moderate in the mid vessel and mild in the distal segment. Otherwise, there is no evidence of atherosclerotic obstruction.,4. ,CIRCUMFLEX ARTERY: , The circumflex gives rise to two large extremely tortuous marginal vessels that extend towards the apex. Angiographically, the circumflex artery is normal.,CONCLUSION: , This is a 70-year-old female with above clinical and cardiovascular history, who has angiographic evidence of a large anterior apical and inferior apical wall motion abnormality with angiographically patent coronary arteries with two segments of myocardial bridging involving the mid and distal left anterior descending artery. These angiographic findings are consistent with Takasubo syndrome, aka apical ballooning syndrome. The patient will be treated medically.

Left heart catheterization with ventriculography, selective coronary angiography. Standard Judkins, right groin. Catheters used were a 6 French pigtail, 6 French JL4, 6 French JR4.

Cardiovascular / Pulmonary

Heart Catheterization, Ventriculography, & Angiography - 3

NAME OF PROCEDURE: , Left heart catheterization with ventriculography, selective coronary angiography.,INDICATIONS: , Acute coronary syndrome.,TECHNIQUE OF PROCEDURE: , Standard Judkins, right groin. Catheters used were a 6 French pigtail, 6 French JL4, 6 French JR4. ,ANTICOAGULATION: ,The patient was on heparin at the time.,COMPLICATIONS: , None.,I reviewed with the patient the pros, cons, alternatives, risks of catheterization and sedation including myocardial infarction, stroke, death, damage to nerve, artery or vein in the leg, perforation of a cardiac chamber, dissection of an artery requiring countershock, infection, bleeding, ATN allergy, need for cardiac surgery. All questions were answered, and the patient desired to proceed.,HEMODYNAMIC DATA: ,Aortic pressure was in the physiologic range. No significant gradient across the aortic valve.,ANGIOGRAPHIC DATA,1. Ventriculogram: The left ventricle is of normal size and shape, normal wall motion, normal ejection fraction.,2. Right coronary artery: Dominant. There was insignificant disease in the system.,3. Left coronary: Left main, left anterior descending and circumflex systems showed no significant disease.,CONCLUSIONS,1. Normal left ventricular systolic function.,2. Insignificant coronary disease.,PLAN: , Based upon this study, medical therapy is warranted. Six-French Angio-Seal was used in the groin.

cardiovascular / pulmonary, standard judkins, french pigtail, selective coronary angiography, heart catheterization, ventriculography, catheterization, angiography,

Left heart catheterization with left ventriculography and selective coronary angiography. Percutaneous transluminal coronary angioplasty and stent placement of the right coronary artery.

Cardiovascular / Pulmonary

Heart Catheterization, Ventriculography, & Angiography - 4

NAME OF PROCEDURE,1. Left heart catheterization with left ventriculography and selective coronary angiography.,2. Percutaneous transluminal coronary angioplasty and stent placement of the right coronary artery.,HISTORY: , This is a 58-year-old male who presented with atypical chest discomfort. The patient had elevated troponins which were suggestive of a myocardial infarction. The patient is suspected of having significant obstructive coronary artery disease, therefore he is undergoing cardiac catheterization.,PROCEDURE DETAILS: , Informed consent was given prior to the patient was brought to the catheterization laboratory. The patient was brought to the catheterization laboratory in postabsorptive state. The patient was prepped and draped in the usual sterile fashion, 2% Xylocaine solution was used to anesthetize the right femoral region. Using modified Seldinger technique, a 6-French arterial sheath was placed. Then, the patient had already been on heparin. Then, a Judkins left 4 catheter was intubated into the left main coronary artery. Several projections were obtained and the catheter was removed. A 3DRC catheter was intubated into the right coronary artery. Several projections were obtained and the catheter was removed. Then, a 3DRC guiding catheter was intubated into the right coronary artery. Then, a universal wire was advanced across the lesion into the distal right coronary artery. Integrilin was given. Then, a 3.0 x 12 Voyager balloon was inflated at 13 atmospheres for 30 seconds. Then, a projection was obtained. Then, a 3.0 x 15 Vision stent was placed into the distal right coronary artery. The stent was deployed at 15 atmospheres for 25 seconds. Post stent, the patient was given intracoronary nitroglycerin after one projection. Then, there was an attempt to place the intervention wire across the third posterolateral branch which was partially obstructed and this was not successful. Then, a pilot 150 wire was advanced across the lesion. Then, attempt to place the 2.0 x 8 power saver across the lesion was performed. However, it was felt that there was adequate flow and no further intervention needed to be performed. Then, the stent delivery system was removed. A pigtail catheter was placed into the left ventricle. Hemodynamics followed by left ventriculography was performed. Then, a pullback gradient was performed and the catheter was removed. Then, the right femoral artery was visualized and using angiography and then an Angio-Seal was applied. The patient was transferred back to his room in good condition.,FINDINGS,1. Hemodynamics: The opening aortic pressure was 116/61 with a mean of 64. The opening left ventricular pressure was 112 with end-diastolic pressure of 23. LV pressure on pullback was 106 with end-diastolic pressure of 21. Aortic pressure was 111/67 with a mean of 87. The closing pressure was 110/67.,2. Left ventriculography: The left ventricle was of normal cavity, size, and wall thickness. There is a mild anterolateral hypokinesis and moderate inferior and inferoapical hypokinesis. The overall systolic function appeared to be mildly reduced with ejection fraction between 40% and 45%. The mitral valve had no significant prolapse or regurgitation. The aortic valve appeared to be trileaflet and moved normally.,3. Coronary angiography: The left main is a normal-caliber vessel. This bifurcates into the left anterior descending and circumflex arteries. The left main is free of any significant obstructive coronary artery disease. The left anterior descending is a large vessel that extends to the apex. It gives off approximately 10 septal perforators and 5 diagonal branches. The first diagonal branch was large. The left anterior descending had mild irregularities, but no high-grade disease. The left circumflex is a nondominant vessel, which gives rise to two obtuse marginal branches. The two obtuse marginal branches are large. There is a relatively small left atrial branch. The left circumflex had a 50% stenosis after the first obtuse marginal branch. The rest of the vessel is moderately irregular, but no high-grade disease. The right coronary artery appears to be a dominant vessel, which gives rise to three right ventricular branches, four posterior lateral branches, two right atrial branches, and two small conus branches. The right coronary artery had moderate disease in its proximal segment with multiple areas of plaquing but no high-grade disease. However, distal between the second and third posterolateral branch, there is a 90% stenosis. The rest of the vessels had mild irregularities, but no high-grade disease. Then percutaneous transluminal coronary angioplasty of the right coronary artery resulted in a 20% residual stenosis. Then, after stent placement there was 0% residual stenosis; however, there was partial occlusion of the third posterolateral branch. Then, a wire was advanced through this and there was improvement of flow. There is improvement from TIMI grade 2 to TIMI grade 3 flow.,CLINICAL IMPRESSION,1. Successful percutaneous transluminal angioplasty and stent placement of the right coronary artery.,2. Two-vessel coronary artery disease.,3. Elevated left ventricular end-diastolic pressure.,4. Mild anterolateral and moderate inferoapical hypokinesis.,RECOMMENDATIONS,1. Integrilin.,2. Bed rest.,3. Risk factor modification.,4. Thallium scintigraphy in approximately six weeks.

cardiovascular / pulmonary, heart catheterization, ventriculography, selective coronary angiography., angioplasty, stent placement, transluminal, percutaneous, coronary artery, coronary angiography, coronary angioplasty, diastolic pressure, obtuse marginal, percutaneous transluminal, catheterization, artery, coronary, angiography

Left heart catheterization with ventriculography, selective coronary arteriographies, successful stenting of the left anterior descending diagonal.

Cardiovascular / Pulmonary

Heart Catheterization, Ventriculography, & Angiography - 2

NAME OF PROCEDURE: , Left heart catheterization with ventriculography, selective coronary arteriographies, successful stenting of the left anterior descending diagonal.,INDICATION:, Recurrent angina. History of coronary disease.,TECHNICAL PROCEDURE: , Standard Judkins, right groin.,CATHETERS USED:, 6-French pigtail, 6-French JL4, 6-French JR4.,ANTICOAGULATION: , 2000 of heparin, 300 of Plavix, was begun on Integrilin.,COMPLICATIONS: , None.,STENT: , For stenting we used a 6-French left Judkins guide. Stent was a 275 x 13 Zeta.,DESCRIPTION OF PROCEDURE: , I reviewed with the patient the pros, cons, alternatives and risks of catheterization and sedation including myocardial infarction, stroke, death, damage to nerve, artery or vein in the leg, perforation of cardiac chamber, resection of an artery, arrhythmia requiring countershock, infection, bleeding, allergy, and need for vascular surgery. All questions were answered and the patient decided to proceed.,HEMODYNAMIC DATA: , Aortic pressure was within physiologic range. There was no significant gradient across the aortic valve.,ANGIOGRAPHIC DATA,1. Ventriculogram: Left ventricle was of normal size and shape with normal wall motion, normal ejection fraction.,2. Right coronary artery: Dominant. There was a lesion in the proximal portion in the 60% range, insignificant disease distally.,3. Left coronary artery: The left main coronary artery showed insignificant disease. The circumflex arose, showed about 30% proximally. Left anterior descending arose and the previously placed stent was perfectly patent. There was a large diagonal branch which showed 90% stenosis in its proximal portion. There was a lesion in the 30% to 40% range even more proximal.,I reviewed with the patient the options of medical therapy, intervention on the culprit versus bypass surgery. He desired that we intervene.,Successful stenting of the left anterior descending, diagonal. The guide was placed in the left main. We easily crossed the lesion in the diagonal branch of the left anterior descending. We advanced, applied and post-dilated the 275 x 13 stent. Final angiography showed 0% residual at the site of previous 90% stenosis. The more proximal 30% to 40% lesion was unchanged.,CONCLUSION,1. Successful stenting of the left anterior descending/diagonal. Initially there was 90% in the diagonal after stenting. There was 0% residual. There was a lesion a bit more proximal in the 40% range.,2. Left anterior descending stent remains patent.,3. 30% in the circumflex.,4. 60% in the right coronary.,5. Ejection fraction and wall motion are normal.,PLAN: , We have stented the culprit lesion. The patient will receive a course of aspirin, Plavix, Integrilin, and statin therapy. We used 6-French Angio-Seal in the groin. All questions have been answered. I have discussed the possibility of restenosis, need for further procedures.

Selective coronary angiography, left heart catheterization, and left ventriculography. Severe stenosis at the origin of the large diagonal artery and subtotal stenosis in the mid segment of this diagonal branch.

Cardiovascular / Pulmonary

Heart Catheterization, Ventriculography, & Angiography - 11

NAME OF PROCEDURES,1. Selective coronary angiography.,2. Left heart catheterization.,3. Left ventriculography.,PROCEDURE IN DETAIL: ,The right groin was sterilely prepped and draped in the usual fashion. The area of the right coronary artery was anesthetized with 2% lidocaine and a 4-French sheath was placed. Conscious sedation was obtained using a combination of Versed 1 mg and fentanyl 50 mcg. A left #4, 4-French, Judkins catheter was placed and advanced through the ostium of the left main coronary artery. Because of difficulty positioning the catheter, the catheter was removed and a 6-French sheath was placed and a 6-French #4 left Judkins catheter was placed. This was advanced through the ostium of the left main coronary artery where selective angiograms were performed. Following this, the 4-French right Judkins catheter was placed and angiograms of the right coronary were performed. A pigtail catheter was placed and a left heart catheterization was performed, followed by a left ventriculogram. The left heart pullback was performed. The catheter was removed and a small injection of contrast was given to the sheath. The sheath was removed over a wire and an Angio-Seal was placed. There were no complications. Total contrast media was 200 mL of Optiray 350. Fluoroscopy time 5.3 minutes. Total x-ray dose is 1783 mGy.,HEMODYNAMICS: ,Rhythm is sinus throughout the procedure. LV pressure of 155/22 mmHg, aortic pressure of 160/80 mmHg. LV pullback demonstrates no gradient.,The right coronary artery is a nondominant vessel and free of disease. This also gives rise to the conus branch and two RV free wall branches. The left main has minor plaquing in the inferior aspect measuring no more than 10% to 15%. This vessel then bifurcates into the LAD and circumflex. The circumflex is a large caliber vessel and is dominant. This vessel gives rise to a large first marginal artery, a moderate sized second marginal branch, and additionally gives rise to a large third marginal artery and the PDA. There was a very eccentric and severe stenosis in the proximal circumflex measuring approximately 90% in severity. The origin of the first marginal artery has a severe stenosis measuring approximately 90% in severity. The distal circumflex has a 60% lesion just prior to the origin of the third marginal branch and PDA.,The proximal LAD is ectatic. The LAD gives rise to a large first diagonal artery that has a 90% lesion in its origin and a subtotal occlusion midway down the diagonal. Distal to the origin of this diagonal branch, there is another area of ectasia in the LAD, followed by an area of stenosis that in some views is approximately 50% in severity.,The left ventriculogram demonstrates hypokinesis of the distal half of the inferior wall. The overall ejection fraction is preserved. There is moderate dilatation of the aortic root. The calculated ejection fraction is 63%.,IMPRESSION,1. Left ventricular dysfunction as evidenced by increased left ventricular end diastolic pressure and hypokinesis of the distal inferior wall.,2. Coronary artery disease with high-grade and complex lesion in the proximal portion of the dominant large circumflex coronary artery. There is subtotal stenosis at the origin of the first obtuse marginal artery.,3. A 60% stenosis in the distal circumflex.,4. Ectasia of the proximal left anterior descending with 50% stenosis in the mid left anterior descending.,5. Severe stenosis at the origin of the large diagonal artery and subtotal stenosis in the mid segment of this diagonal branch.

cardiovascular / pulmonary, coronary angiography, catheterization, ventriculography, heart catheterization, coronary artery, stenosis, artery, angiography

Left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery.

Cardiovascular / Pulmonary

Heart Catheterization, Ventriculography, & Angiography - 10

PROCEDURE: , Left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery.,PROCEDURE IN DETAIL: ,The patient was brought to the Catheterization Laboratory. After informed consent, he was medicated with Versed and fentanyl. The right groin was prepped and draped, and infiltrated with 2% Xylocaine. Percutaneously, #6-French arterial sheath was placed. Selective native left and right coronary angiography was performed followed by left ventricular angiography. The patient had a totally occluded right coronary. We initially started with a JR4 guide. We were able to a sport wire through the total occlusion and saw a very tight stenosis. We were able to get a 30 x 13 mm power saver balloon into the stenosis and dilated. We then attempted to put a 30 x 12 mm stent across the stenosis, but we had very little guide support, the guide kept coming out. We then switched to an AL1 guide and that too did not enable us to get anything to cross this lesion. We finally had to go an AL2 guide, we were concerned that this could cause some proximal dissection. That guided seated, we did have initial difficulty getting the wire back across the stenosis, and we did see a little staining suggesting we did have some tearing from the guide tip. The surgeons were put on notice in case we could not get this vessel open, but we were able to re-cross with a sport wire. We then re-dilated the area of stenosis and with good guide support, we were able to get a 30 x 23 mm Vision stent, where the lesion was and post-dilated it to 18 atmospheres. Routine angiography did show that the distal posterolateral branch seems to be occluded, whether this was from distal wire dissection or distal thrombosis was unclear, but we were able to re-wire that area and get a 25 x12 Vision balloon and dilate the area and re-establish flow to the small segment. We then came back because of the residual dissection proximal to the first stent and put a 30 x15 mm Vision stent at 18 atmospheres. Final angiography showed resolution of the dissection. We could see a little staining extrinsic to the stent. No perforation and excellent flow. During the intervention, we did give a bolus and drip of Angiomax. At the end of the procedure, we stopped the Angiomax and gave 600 mg of Plavix. We did a right femoral angiogram; however, the Angio-Seal plug could not take, so we used manual pressure and a Femostop. We transported the patient to his room in stable condition.,ANGIOGRAPHIC DATA:, Left main coronary is normal. Left anterior descending artery has a fair amount of wall disease proximally about 50 to 60% stenosis of the LAD before it bifurcates into diagonal. The diagonal does appear to have about 50% osteal stenosis. There is a lot of plaquing further down the diagonal, but good flow. The rest of the LAD looked good pass the proximal 60% stenosis and after the diagonal branch. Circumflex artery was nondominant vessel, consisting of an obtuse marginal vessel. The first obtuse marginal had a long 50% narrowing and then the AV groove branch was free of any disease. Some mild collaterals to the right were seen. Right coronary angiography revealed a total occlusion of the right coronary, just about 0.5 cm after its origin. After we got a wire across the area of occlusion, we could see some thrombosis and a 99% stenosis just at the curve. Following the balloon angioplasty, we established good flow down the distal vessel. We still had about residual 70% stenosis. When we had to go back with the AL2 guide, we could see a little bit of staining in the proximal portion of the vessel that we did not notice previously and we felt that the tip of the guide caused a little bit of intimal dissection. We re-dilated and then deployed. Repeat angiography now did show some hang up off dye distally. We never did have the wire that far down, so this was probably felt to be due to distal embolization of some thrombus. After deploying the stent, we had total resolution of the original lesion. We then directed our attention to the posterolateral branch, which the remainder of the vessel was patent giving off a large PDA. The posterolateral branch appeared to be occluded in its mid portion. We got a wire through and dilated this. We then came back and put a second stent in the proximal area of the right coronary proximal and abutting to the previous stent. Repeat angiography now showed no significant dissection, a little bit of contrast getting extrinsic to the stent probably in a little subintimal pouch, but this was excluded by the stent. There were no filling defects in the stent and excellent flow. The distal posterolateral branch did open up, although it was little under-filled and there may have been some mild residual disease there.,IMPRESSION: , Atherosclerotic heart disease with total occlusion of right coronary, successfully stented to zero residual with repair of a small proximal dissection. Minor distal disease of the posterolateral branch and 60% proximal left anterior descending coronary artery stenosis and 50% diagonal stenosis along with 50% stenosis of the first obtuse marginal branch.

cardiovascular / pulmonary, heart catheterization, coronary angiography, ventricular angiography, intercoronary stenting, intercoronary, coronary, stenting, stenosis, angiography

Left heart cath, selective coronary angiography, LV gram, right femoral arteriogram, and Mynx closure device. Normal stress test.

Cardiovascular / Pulmonary

Heart Catheterization & Angiography - 1

CLINICAL INDICATION: ,Normal stress test.,PROCEDURES PERFORMED:,1. Left heart cath.,2. Selective coronary angiography.,3. LV gram.,4. Right femoral arteriogram.,5. Mynx closure device.,PROCEDURE IN DETAIL: , The patient was explained about all the risks, benefits, and alternatives of this procedure. The patient agreed to proceed and informed consent was signed.,Both groins were prepped and draped in the usual sterile fashion. After local anesthesia with 2% lidocaine, a 6-French sheath was inserted in the right femoral artery. Left and right coronary angiography was performed using 6-French JL4 and 6-French 3DRC catheters. Then, LV gram was performed using 6-French pigtail catheter. Post LV gram, LV-to-aortic gradient was obtained. Then, the right femoral arteriogram was performed. Then, the Mynx closure device was used for hemostasis. There were no complications.,HEMODYNAMICS: , LVEDP was 9. There was no LV-to-aortic gradient.,CORONARY ANGIOGRAPHY:,1. Left main is normal. It bifurcates into LAD and left circumflex.,2. Proximal LAD at the origin of big diagonal, there is 50% to 60% calcified lesion present. Rest of the LAD free of disease.,3. Left circumflex is a large vessel and with minor plaque.,4. Right coronary is dominant and also has proximal 40% stenosis.,SUMMARY:,1. Nonobstructive coronary artery disease, LAD proximal at the origin of big diagonal has 50% to 60% stenosis, which is calcified.,2. RCA has 40% proximal stenosis.,3. Normal LV systolic function with LV ejection fraction of 60%.,PLAN: , We will treat with medical therapy. If the patient becomes symptomatic, we will repeat stress test. If there is ischemic event, the patient will need surgery for the LAD lesion. For the time being, we will continue with the medical therapy.,

cardiovascular / pulmonary, selective coronary angiography, lv gram, femoral, mynx, heart cath, mynx closure device, heart catheterization, femoral arteriogram, stress test, coronary angiography, heart, arteriogram, catheterization, lad, coronary, angiography,

Right and left heart catheterization, left ventriculogram, aortogram, and bilateral selective coronary angiography. The patient is a 48-year-old female with severe mitral stenosis diagnosed by echocardiography, moderate aortic insufficiency and moderate to severe pulmonary hypertension who is being evaluated as a part of a preoperative workup for mitral and possible aortic valve repair or replacement.

Cardiovascular / Pulmonary

Heart Catheterization & Ventriculogram

PROCEDURE PERFORMED:,1. Right heart catheterization.,2. Left heart catheterization.,3. Left ventriculogram.,4. Aortogram.,5. Bilateral selective coronary angiography.,ANESTHESIA:, 1% lidocaine and IV sedation including Versed 1 mg.,INDICATION:, The patient is a 48-year-old female with severe mitral stenosis diagnosed by echocardiography, moderate aortic insufficiency and moderate to severe pulmonary hypertension who is being evaluated as a part of a preoperative workup for mitral and possible aortic valve repair or replacement. She has had atrial fibrillation and previous episodes of congestive heart failure. She has dyspnea on exertion and occasionally orthopnea and paroxysmal nocturnal dyspnea.,PROCEDURE:, After the risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient in detail, informed consent was obtained, both verbally and in writing. The patient was taken to the Cardiac Catheterization Lab where the procedure was performed. The right inguinal area was thoroughly cleansed with Betadine solution and the patient was draped in the usual manner. 1% lidocaine solution was used to anesthetize the right inguinal area. Once adequate anesthesia had been attained, a thing wall Argon needle was used to cannulate the right femoral vein. A guidewire was advanced into the lumen of the vein without resistance. The needle was removed and the guidewire was secured to the sterile field. The needle was flushed and then used to cannulate the right femoral artery. A guidewire was advanced through the lumen of the needle without resistance. A small nick was made in the skin and the needle was removed. This pressure was held. A #6 French arterial sheath was advanced over the guidewire without resistance. The dilator and guidewire were removed. FiO2 sample was obtained and the sheath was flushed. An #8 French sheath was advanced over the guidewire into the femoral vein after which the dilator and guidewire were removed and the sheath was flushed. A Swan-Ganz catheter was advanced through the venous sheath into a pulmonary capillary was positioned and the balloon was temporarily deflated. An angulated pigtail catheter was advanced into the left ventricle under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to a manifold and flushed. Left ventricular pressures were continuously measured and the balloon was re-inflated and pulmonary capillary wedge pressure was remeasured. Using dual transducers together and the mitral valve radius was estimated. The balloon was deflated and mixed venous sample was obtained. Hemodynamics were measured. The catheter was pulled back in to the pulmonary artery right ventricle and right atrium. The right atrial sample was obtained and was negative for shunt. The Swan-Ganz catheter was then removed and a left ventriculogram was performed in the RAO projection with a single power injection of non-ionic contrast material. Pullback was then performed which revealed a minimal LV-AO gradient. Since the patient had aortic insufficiency on her echocardiogram, an aortogram was performed in the LAO projection with a single power injection of non-ionic contrast material. The pigtail catheter was then removed and a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. The ostium of the left main coronary artery was carefully engaged. Using multiple hand injections of non-ionic contrast material, the left coronary system was evaluated in different views. This catheter was then removed and a Judkins right #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. The ostium of the right coronary artery was then engaged and using hand injections of non-ionic contrast material, the right coronary system was evaluated in different views. This catheter was removed. The sheaths were flushed final time. The patient was taken to the Postcatheterization Holding Area in stable condition.,FINDINGS:,HEMODYNAMICS: , Right atrial pressure 9 mmHg, right ventricular pressure is 53/14 mmHg, pulmonary artery pressure 62/33 mmHg with a mean of 46 mmHg. Pulmonary capillary wedge pressure is 29 mmHg. Left ventricular end diastolic pressure was 13 mmHg both pre and post left ventriculogram. Cardiac index was 2.4 liters per minute/m2. Cardiac output 4.0 liters per minute. The mitral valve gradient was 24.5 and mitral valve area was calculated to be 0.67 cm2. The aortic valve area is calculated to be 2.08 cm2.,LEFT VENTRICULOGRAM: , No segmental wall motion abnormalities were noted. The left ventricle was somewhat hyperdynamic with an ejection fraction of 70%. 2+ to 3+ mitral regurgitation was noted.,AORTOGRAM: , There was 2+ to 3+ aortic insufficiency noted. There was no evidence of aortic aneurysm or dissection.,LEFT MAIN CORONARY ARTERY: , This was a moderate caliber vessel and it is rather long. It bifurcates into the LAD and left circumflex coronary artery. No angiographically significant stenosis is noted.,LEFT ANTERIOR DESCENDING ARTERY:, The LAD begins as a moderate caliber vessel ________ anteriorly in the intraventricular groove. It tapers in its mid portion to become small caliber vessel. Luminal irregularities are present, however, no angiographically significant stenosis is noted.,LEFT CIRCUMFLEX CORONARY ARTERY: , The left circumflex coronary artery begins as a moderate caliber vessel. Small obtuse marginal branches are noted and this is the nondominant system. Lumen irregularities are present throughout the circumflex system. However no angiographically significant stenosis is noted.,RIGHT CORONARY ARTERY: , This is the moderate caliber vessel and it is the dominant system. No angiographically significant stenosis is noted, however, mild luminal irregularities are noted throughout the vessel.,IMPRESSION:,1. Nonobstructive coronary artery disease.,2. Severe mitral stenosis.,3. 2+ to 3+ mitral regurgitation.,4. 2+ to 3+ aortic insufficiency.

Left heart catheterization, bilateral selective coronary angiography, saphenous vein graft angiography, left internal mammary artery angiography, and left ventriculography.

Cardiovascular / Pulmonary

Heart Catheterization, Ventriculography, & Angiography

PROCEDURES PERFORMED:,1. Left heart catheterization.,2. Bilateral selective coronary angiography.,3. Saphenous vein graft angiography.,4. Left internal mammary artery angiography.,5. Left ventriculography.,INDICATIONS: , Persistent chest pain on maximum medical therapy with known history of coronary artery disease, status post coronary artery bypass grafting in year 2000.,PROCEDURE: , After the risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient in detail, an informed consent was obtained both verbally and in writing. The patient was taken to the Cardiac Catheterization Suite where the right femoral region was prepped and draped in the usual sterile fashion. 1% lidocaine solution was then used to infiltrate the skin overlying the right femoral artery. Once adequate anesthesia had been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right femoral artery. A steel guidewire was then inserted through the needle into the vascular lumen without resistance. A small nick was then made in the skin and its pressure was held. The needle was removed over the guidewire. A #6 French sheath was then advanced over the guidewire into the vascular lumen without resistance. The guidewire and dilator were then removed. The sheath was then flushed. Next, angulated pigtail catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of the guidewire. The catheter was then advanced into the left ventricle. The guidewire was then removed. The catheter was connected to the manifold and flushed. LVEDP was then measured and found to be favorable for a left ventriculogram. The left ventriculogram was performed in the RAO position with a single power injection of non-ionic contrast material. LVEDP was then remeasured. Pullback was then performed, which failed to reveal an LVAO gradient. The catheter was then removed. Next, a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. Using hand injections of non-ionic contrast material, the left coronary system was evaluated in several different views. Once adequate study has been performed, the catheter was removed. Next, a Judkins right #4 catheter was then advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. The ostium of the saphenous vein graft was engaged using hand injections of non-ionic contrast material. The saphenous vein graft was visualized in several different views. The Judkins right catheter was then advanced and the native coronary artery was engaged using hand injections of non-ionic contrast material. Right coronary system was evaluated in several different views. Once adequate study has been performed, the catheter was retracted. We were unable to engage the left subclavian artery thus the catheter was removed over an exchange wire. Next, a multipurpose catheter was advanced over the exchange wire. The wire was then easily passed into the left subclavian artery. The multipurpose catheter was then removed. LIMA catheter was then exchanged over the wire into the left subclavian artery. The guidewire was removed and the catheter was connected to the manifold and flushed. LIMA graft was then engaged using hand injections of non-ionic contrast material. The LIMA graft was evaluated in several different views. Once adequate study has been performed, the LIMA catheter was retracted under fluoroscopic guidance. The sheath was flushed for the final time. The patient was returned to the cardiac catheterization holding area in stable and satisfactory condition.,FINDINGS:,LEFT VENTRICULOGRAM: , There is no evidence of any wall motion abnormalities with an estimated ejection fraction of 60%. Left ventricular end-diastolic pressure was 24 mmHg preinjection and 26 mmHg postinjection. There is no mitral regurgitation. There is no LVAO or pullback.,LEFT MAIN CORONARY ARTERY: , The left main is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries. There is no evidence of any hemodynamically significant stenosis.,LEFT ANTERIOR DESCENDING ARTERY: , The LAD is a small caliber vessel, which traverses through the intraventricular groove and wraps around the apex of the heart. There are luminal irregularities from the mid to distal portion. There is noted to be antegrade flow in the LIMA to LAD graft. There are very small diagonal branches, which are diffusely diseased.,CIRCUMFLEX ARTERY: , The circumflex is a small caliber vessel, which traverses through the atrioventricular groove. There are minor luminal irregularities throughout. There are very small obtuse marginal branches, which are diffusely diseased.,RIGHT CORONARY ARTERY:, The RCA is a small vessel with luminal irregularities throughout. The RCA is the dominant coronary artery.,Left internal mammary artery graft to the left anterior descending artery failed to demonstrate any hemodynamically significant stenosis. Saphenous vein graft to the obtuse marginal branches is a Y-graft, which bifurcates to the first obtuse marginal and the obtuse marginal branch. The saphenous vein graft to the obtuse marginal branches is widely patent without any evidence of hemodynamically significant disease.,IMPRESSION:,1. Diffusely diseased native vessels.,2. Saphenous vein graft to the obtuse marginal branch is widely patent.,3. Left internal mammary artery graft to the left anterior descending artery is patent.,4. Normal left ventricular function with ejection fraction of 60%.,5. Mildly elevated left-sided filling pressures.,PLAN:,1. The patient is to continue on her current medical regimen, which includes beta-blocker, aspirin, statin, and Plavix. The patient is unable to tolerate a long-acting nitrate, thus this will be discontinued.,2. We will add Norvasc 5 mg daily as well as hydrochlorothiazide 25 mg daily.,3. Risk factor modification was discussed with the patient including diet control as well as tobacco cessation.,4. The patient will need to be monitored closely for close lipid control as well as blood pressure control.

Left heart catheterization and bilateral selective coronary angiography. Left ventriculogram was not performed.

Cardiovascular / Pulmonary

Heart Catheterization & Angiography - 2

PROCEDURES PERFORMED:,1. Left heart catheterization.,2. Bilateral selective coronary angiography.,3. Left ventriculogram was not performed.,INDICATION: , Non-ST elevation MI.,PROCEDURE: , After risks, benefits, and alternatives of the above-mentioned procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing. The patient was taken to cardiac catheterization suite where the right femoral region was prepped and draped in the usual sterile fashion. 1% lidocaine solution was used to infiltrate the skin overlying the right femoral artery. Once adequate anesthesia had been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right femoral artery. A steel guidewire was inserted through the needle into the vascular lumen without resistance. A small nick was then made in the skin. The pressure was held. The needle was removed over the guidewire. Next, a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. The ostium of the left main coronary artery was engaged. Using hand injections of nonionic contrast material, the left coronary system was evaluated in several different views. Once an adequate study had been performed, the catheter was removed from the ostium of the left main coronary artery and a steel guidewire was inserted through the catheter. The catheter was then removed over the guidewire.,Next, a Judkins right #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to manifold and flushed. The catheter did slip into the left ventricle. During the rotation, the LVEDP was then measured. The ostium of the right coronary artery was then engaged. Using hand injections of nonionic contrast material, the right coronary system was evaluated in several different views. Once adequate study has been performed, the catheter was then removed. The sheath was lastly flushed for the final time.,FINDINGS:,LEFT MAIN CORONARY ARTERY: , The left main coronary artery is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries. There is no evidence of any hemodynamically significant stenosis.,LEFT ANTERIOR DESCENDING ARTERY: , The LAD is a moderate caliber vessel, which is subtotaled in its mid portion for approximately 1.5 cm to 1 cm with subsequent TIMI-I flow distally. The distal portion was diffusely diseased. The proximal portion otherwise shows minor luminal irregularities. The first diagonal branch demonstrated minor luminal irregularities throughout.,CIRCUMFLEX ARTERY: ,The circumflex is a moderate caliber vessel, which traverses through the atrioventricular groove. There is a 60% proximal lesion and a 90% mid lesion prior to the takeoff of the first obtuse marginal branch. The first obtuse marginal branch demonstrates minor luminal irregularities throughout.,RIGHT CORONARY ARTERY: , The RCA is a moderate caliber vessel, which demonstrates a 90% mid stenotic lesion. The dominant coronary artery gives off the posterior descending artery and posterolateral artery. The left ventricular end-diastolic pressure was approximately 22 mmHg. It should be noted that during injection of the contrast agent that there was ST elevation in the inferior leads, which resolved after the injection was complete.,IMPRESSION:,1. Three-vessel coronary artery disease involving a subtotaled left anterior descending artery with TIMI-I flow distally and 90% circumflex lesion and 90% right coronary artery lesion.,2. Mildly elevated left-sided filling pressures.,PLAN:,1. The patient will be transferred to Providence Hospital today for likely PCI of the mid LAD lesion with a surgical evaluation for a coronary artery bypass grafting. These findings and plan were discussed in detail with the patient and the patient's family. The patient is agreeable.,2. The patient will be continued on aggressive medical therapy including beta-blocker, aspirin, ACE inhibitor, and statin therapy. The patient will not be placed on Plavix secondary to the possibility for coronary bypass grafting. In light of the patient's history of cranial aneurysmal bleed, the patient will be held off of Lovenox and Integrilin.

cardiovascular / pulmonary, non-st elevation, coronary angiography, ventriculogram, heart catheterization, bypass grafting, catheterization, coronary, artery, angiography, luminal, branch, descending, circumflex, vessel, guidewire,

Left heart catheterization, left ventriculography, coronary angiography, and successful stenting of tight lesion in the distal circumflex and moderately tight lesion in the mid right coronary artery.

Cardiovascular / Pulmonary

Heart Catheterization, Ventriculography, & Angiography - 1

PROCEDURE:, Left heart catheterization, left ventriculography, coronary angiography, and successful stenting of tight lesion in the distal circumflex and moderately tight lesion in the mid right coronary artery. This gentleman has had a non-Q-wave, troponin-positive myocardial infarction, complicated by ventricular fibrillation.,PROCEDURE DETAILS:, The patient was brought to the catheterization lab, the chart was reviewed, and informed consent was obtained. Right groin was prepped and draped sterilely and infiltrated 2% Xylocaine. Using the Seldinger technique, a #6-French sheath was placed in the right femoral artery. ACT was checked and was low. Additional heparin was given. A #6-French pigtail catheter was passed. Left ventriculography was performed. The catheter was exchanged for a #6-French JL4 catheter. Nitroglycerin was given in the left main. Left coronary angiography was performed. The catheter was exchanged for a #6-French __________ coronary catheter. Nitroglycerin was given in the right main, and right coronary angiography was performed. Films were closely reviewed, and it was felt that he had a significant lesion in the RCA and the distal left circumflex is basically an OM. Considering his age and his course, it was elected to stent both these lesions. ReoPro was started, and the catheter was exchanged for a #6-French JR4 guide. ReoPro was given in the RCA to prevent no reflow. A 0.014 Universal wire was passed. The lesion was measured. A 4.5 x 18-mm stent was passed and deployed to moderate pressures with an excellent result. The catheter was removed and exchanged for a #6-French JL4 guide. The same wire was passed down the circumflex and the lesion measured. A 2.75 x 15-mm stent was deployed to a moderate pressure with an excellent result. Plavix was given. The catheter was removed and sheath was in place. The results were explained to the patient and his wife.,FINDINGS,1. Hemodynamics. Please see attached sheet for details. ED was 20. There is no gradient across the aortic valve.,2. Left ventriculography revealed septum upper limits of normal size with borderline normal LV systolic function with borderline normal wall motion, in which there is a question of diffuse, very minimal global hypokinesis. There is mild MR noted.,3. Coronary angiography.,a. Left main normal.,b. LAD. Some very minimal luminal irregularities. There is a 1st diagonal which has a branch that is 1.5 mm with a proximal 50% narrowing.,c. Left circumflex is basically a marginal branch, in which distally there was a long 98% lesion.,d. The RCA is large dominant and has a mid somewhat long 70% lesion.,4. Stenting.,a. The RCA revealed a lesion that went from 70% to a -5%.,B. The circumflex went from 95% to -5%.,CONCLUSION,1. Decreased left ventricular compliance.,2. Borderline normal overall ejection fraction with mild mitral regurgitation.,3. Triple-vessel coronary artery disease with a borderline lesion in a very small branch of the 1st diagonal and significant lesions in the mid dominant right coronary artery and the distal circumflex, which is basically old.,4. Successful stenting of the right coronary artery and the circumflex.,RECOMMENDATION: , ReoPro/stent protocol, Plavix for at least 9 months, aggressive control of risk factors. I have ordered Zocor and a fasting lipid panel.,AICD will be considered, realizing when this gentleman becomes ischemic he is at high risk for fibrillating.

cardiovascular / pulmonary, heart catheterization, ventriculography, coronary angiography, stenting, distal circumflex, coronary artery, coronary, lesion, catheterization, cardiac, angiography, heart, rca, artery, circumflex,

Right heart catheterization. Refractory CHF to maximum medical therapy.

Cardiovascular / Pulmonary

Heart Catheterization - 2

PROCEDURE PERFORMED:, Right heart catheterization.,INDICATION: , Refractory CHF to maximum medical therapy.,PROCEDURE: , After risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient and the patient's family in detail, informed consent was obtained both verbally and in writing. The patient was taken to Cardiac Catheterization Suite where the right internal jugular region was prepped and draped in the usual sterile fashion. 1% lidocaine solution was used to infiltrate the skin overlying the right internal jugular vein. Once adequate anesthesia has been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right internal jugular vein. A steel guidewire was then inserted through the needle into the vessel without resistance. Small nick was then made in the skin and the needle was removed. An #8.5 French venous sheath was then advanced over the guidewire into the vascular lumen without resistance. The guidewire and dilator were then removed. The sheath was then flushed. A Swan-Ganz catheter was inserted to 20 cm and the balloon was inflated. Under fluoroscopic guidance, the catheter was advanced into the right atrium through the right ventricle and into the pulmonary artery wedge position. Hemodynamics were measured along the way. Pulmonary artery saturation was obtained. The Swan was then kept in place for the patient to be transferred to the ICU for further medical titration. The patient tolerated the procedure well. The patient returned to the cardiac catheterization holding area in stable and satisfactory condition.,FINDINGS:, Body surface area equals 2.04, hemoglobin equals 9.3, O2 is at 2 liters nasal cannula. Pulmonary artery saturation equals 37.8. Pulse oximetry on 2 liters nasal cannula equals 93%. Right atrial pressure is 8, right ventricular pressure equals 59/9, pulmonary artery pressure equals 61/31 with mean of 43, pulmonary artery wedge pressure equals 21, cardiac output equals 3.3 by the Fick method, cardiac index is 1.6 by the Fick method, systemic vascular resistance equals 1821, and transpulmonic gradient equals 22.,IMPRESSION: ,Exam and Swan findings consistent with low perfusion given that the mixed venous O2 is only 38% on current medical therapy as well as elevated right-sided filling pressures and a high systemic vascular resistance.,PLAN: , Given that the patient is unable to tolerate vasodilator therapy secondary to significant orthostasis and the fact that the patient will not respond to oral titration at this point due to lack of cardiac reserve, the patient will need to be discharged home on Primacor. The patient is unable to continue with his dobutamine therapy secondary to nonsustained ventricular tachycardia. At this time, we will transfer the patient to the Intensive Care Unit for titration of the Primacor therapy. We will also increase his Lasix to 80 mg IV q.d. We will increase his amiodarone to 400 mg daily. We will also continue with his Coumadin therapy. As stated previously, we will discontinue vasodilator therapy starting with the Isordil.

cardiovascular / pulmonary, chf, cardiac, catheterization, swan-ganz, heart catheterization, internal jugular, pulmonary artery, heart, jugular, cannulate, vascular, needle, pulmonary, therapy

Left heart catheterization and bilateral selective coronary angiography. The patient is a 65-year-old male with known moderate mitral regurgitation with partial flail of the P2 and P3 gallops who underwent outpatient evaluation for increasingly severed decreased functional capacity and retrosternal chest pain that was aggravated by exertion and decreased with rest.

Cardiovascular / Pulmonary

Heart Cath & Coronary Angiography

PROCEDURE PERFORMED:,1. Left heart catheterization.,2. Bilateral selective coronary angiography.,ANESTHESIA: , 1% lidocaine and IV sedation, including fentanyl 25 mcg.,INDICATION: , The patient is a 65-year-old male with known moderate mitral regurgitation with partial flail of the P2 and P3 gallops who underwent outpatient evaluation for increasingly severed decreased functional capacity and retrosternal chest pain that was aggravated by exertion and decreased with rest. It was accompanied by diaphoresis and shortness of breath. The patient was felt to be a candidate for mitral valve repair versus mitral valve replacement and underwent a stress test as part of his evaluation for chest pain. He underwent adenosine Cardiolite, which revealed 2 mm ST segment depression in leads II, III aVF, and V3, V4, and V5. Stress images revealed left ventricular dilatations suggestive of multivessel disease. He is undergoing evaluation today as a part of preoperative evaluation and because of the positive stress test.,PROCEDURE: , After risks, benefits, alternatives of the above mentioned procedure were explained to the patient in detail, informed consent was obtained both verbally and writing. The patient was taken to the Cardiac Catheterization Laboratory where the procedure was performed. The right inguinal area was sterilely cleansed with a Betadine solution and the patient was draped in the usual manner. 1% lidocaine solution was used to anesthetize the right inguinal area. Once adequate anesthesia had been obtained, a thin-walled Argon needle was used to cannulate the right femoral artery.,The guidewire was then advanced through the lumen of the needle without resistance and a small nick was made in the skin. The needle was removed and a pressure was held. A #6 French arterial sheath was advanced over the guidewire without resistance. The dilator and guidewire were removed and the sheath was flushed. A Judkins left #4 catheter was advanced to the ascending aorta under direct fluoroscopic visualization with the use of the guidewire. The guidewire was removed and the catheter was connected to the manifold and flushed. The ostium of the left main coronary artery was carefully engaged and limited evaluation was performed after noticing that the patient had a significant left main coronary artery stenosis. The catheter was withdrawn from the ostium of the left main coronary artery and the guidewire was inserted through the tip of the catheter. The catheter was removed over guidewire and a Judkins right #4 catheter was advanced to the ascending aorta under direct fluoroscopic visualization with use of a guidewire. The guidewire was removed and the catheter was connected to the manifold and flushed. The ostium of the right coronary artery was carefully engaged and using hand injections of nonionic contrast material, the right coronary artery was evaluated in both diagonal views. This catheter was removed. The sheath was flushed the final time. The patient was taken to the postcatheterization holding area in stable condition.,FINDINGS:,LEFT MAIN CORONARY ARTERY:, This vessel is seen to be heavily calcified throughout its course. Begins as a moderate caliber vessel. There is a 60% stenosis in the distal portion with extension of the lesion to the ostium and proximal portions of the left anterior descending and left circumflex coronary artery.,LEFT ANTERIOR DESCENDING CORONARY ARTERY:, This vessel is heavily calcified in its proximal portion. It is of moderate caliber and seen post anteriorly in the intraventricular groove and wraps around the apex. There is a 90% stenosis in the proximal portion and 90% ostial stenosis in the first and second anterolateral branches. There is sequential 80% and 90% stenosis in the mid-portion of the vessel. Otherwise, the LAD is seen to be diffusely diseased.,LEFT CIRCUMFLEX CORONARY ARTERY: ,This vessel is also calcified in its proximal portion. There is a greater than 90% ostial stenosis, which appears to be an extension of the lesion in the left main coronary artery. There is a greater than 70% stenosis in the proximal portion of the first large obtuse marginal branch, otherwise, the circumflex system is seen to be diffusely diseased.,RIGHT CORONARY ARTERY: , This is a large caliber vessel and is the dominant system. There is diffuse luminal irregularities throughout the vessel and a 80% to 90% stenosis at the bifurcation above the posterior descending artery and posterolateral branch.,IMPRESSION:,1. Three-vessel coronary artery disease as described above.,2. Moderate mitral regurgitation per TEE.,3. Status post venous vein stripping of the left lower extremity and varicosities in both lower extremities.,4. Long-standing history of phlebitis.,PLAN: , Consultation will be obtained with Cardiovascular and Thoracic Surgery for CABG and mitral valve repair versus replacement.

cardiovascular / pulmonary, left heart catheterization, bilateral selective coronary angiography, regurgitation, gallops, diaphoresis, shortness of breath, coronary angiography, proximal portions, catheterization, artery, coronary, bilateral, selective, angiography, mitral, stenosis, vessel, guidewire,

A female for a complete physical and follow up on asthma with allergic rhinitis.

Cardiovascular / Pulmonary

Followup on Asthma

SUBJECTIVE: , This is a 42-year-old white female who comes in today for a complete physical and follow up on asthma. She says her asthma has been worse over the last three months. She has been using her inhaler daily. Her allergies seem to be a little bit worse as well. Her husband has been hauling corn and this seems to aggravate things. She has not been taking Allegra daily but when she does take it, it seems to help somewhat. She has not been taking her Flonase which has helped her in the past. She also notes that in the past she was on Advair but she got some vaginal irritation with that.,She had been noticing increasing symptoms of irritability and PMS around her menstrual cycle. She has been more impatient around that time. Says otherwise her mood is normal during the rest of the month. It usually is worse the week before her cycle and improves the day her menstrual cycle starts. Menses have been regular but somewhat shorter than in the past. Occasionally she will get some spotting after her cycles. She denies any hot flashes or night sweats with this. In reviewing the chart it is noted that she did have 3+ blood with what appeared to be a urinary tract infection previously. Her urine has not been rechecked. She recently had lab work and cholesterol drawn for a life insurance application and is going to send me those results when available.,REVIEW OF SYSTEMS: , As above. No fevers, no headaches, no shortness of breath currently. No chest pain or tightness. No abdominal pain, no heartburn, no constipation, diarrhea or dysuria. Occasional stress incontinence. No muscle or joint pain. No concerns about her skin. No polyphagia, polydipsia or polyuria.,PAST MEDICAL HISTORY: , Significant for asthma, allergic rhinitis and cervical dysplasia.,SOCIAL HISTORY: , She is married. She is a nonsmoker.,MEDICATIONS: , Proventil and Allegra.,ALLERGIES: , Sulfa.,OBJECTIVE:,Vital signs: Her weight is 151 pounds. Blood pressure is 110/60. Pulse is 72. Temperature is 97.1 degrees. Respirations are 20.,General: This is a well-developed, well-nourished 42-year-old white female, alert and oriented in no acute distress. Affect is appropriate and is pleasant.,HEENT: Normocephalic, atraumatic. Tympanic membranes are clear. Conjunctivae are clear. Pupils are equal, round and reactive to light. Nares without turbinate edema. Oropharynx is nonerythematous.,Neck: Supple without lymphadenopathy, thyromegaly, carotid bruit or JVD.,Chest: Clear to auscultation bilaterally.,Cardiovascular: Regular rate and rhythm without murmur.,Abdomen: Soft, nontender, nondistended. Normoactive bowel sounds. No masses or organomegaly to palpation.,Extremities: Without cyanosis or edema.,Skin: Without abnormalities.,Breasts: Normal symmetrical breasts without dimpling or retraction. No nipple discharge. No masses or lesions to palpation. No axillary masses or lymphadenopathy.,Genitourinary: Normal external genitalia. The walls of the vaginal vault are visualized with normal pink rugae with no lesions noted. Cervix is visualized without lesion. She has a moderate amount of thick white/yellow vaginal discharge in the vaginal vault. No cervical motion tenderness. No adnexal tenderness or fullness.,ASSESSMENT/PLAN:,1. Asthma. Seems to be worse than in the past. She is just using her Proventil inhaler but is using it daily. We will add Flovent 44 mcg two puffs p.o. b.i.d. May need to increase the dose. She did get some vaginal irritation with Advair in the past but she is willing to retry that if it is necessary. May also need to consider Singulair. She is to call me if she is not improving. If her shortness of breath worsens she is to call me or go into the emergency department. We will plan on following up for reevaluation in one month.,2. Allergic rhinitis. We will plan on restarting Allegra and Flonase daily for the time being.,3. Premenstrual dysphoric disorder. She may have some perimenopausal symptoms. We will start her on fluoxetine 20 mg one tablet p.o. q.d.,4. Hematuria. Likely this is secondary to urinary tract infection but we will repeat a UA to document clearing. She does have some frequent dysuria but is not having it currently.,5. Cervical dysplasia. Pap smear is taken. We will notify the patient of results. If normal we will go back to yearly Pap smear. She is scheduled for screening mammogram and instructed on monthly self-breast exam techniques. Recommend she get 1200 mg of calcium and 400 U of vitamin D a day.

Left and right heart catheterization and selective coronary angiography. Coronary artery disease, severe aortic stenosis by echo.

Cardiovascular / Pulmonary

Heart Catheterization & Angiography

INDICATION:, Coronary artery disease, severe aortic stenosis by echo.,PROCEDURE PERFORMED:,1. Left heart catheterization.,2. Right heart catheterization.,3. Selective coronary angiography.,PROCEDURE: , The patient was explained about all the risks, benefits and alternatives to the procedure. The patient agreed to proceed and informed consent was signed.,Both groins were prepped and draped in usual sterile fashion. After local anesthesia with 2% lidocaine, 6-French sheath was inserted in the right femoral artery and 7-French sheath was inserted in the right femoral vein. Then right heart cath was performed using 7-French Swan-Ganz catheter. Catheter was placed in the pulmonary capillary wedge position. Pulmonary capillary wedge pressure, PA pressure was obtained, cardiac output was obtained, then RV, RA pressures were obtained. The right heart catheter _______ pulled out. Then selective coronary angiography was performed using 6-French JL4 and 6-French 3DRC catheter. Then attempt was made to cross the aortic valve with 6-French pigtail catheter, but it was unsuccessful. After the procedure, catheters were pulled out, sheath was pulled out and hemostasis was obtained by manual pressure. The patient tolerated the procedure well. There were no complications.,HEMODYNAMICS:,1. Cardiac output was 4.9 per liter per minute. Pulmonary capillary wedge pressure, mean was 7, PA pressure was 20/14, RV 26/5, RA mean pressure was 5.,2. Coronary angiography, left main is calcified _______ dense complex.,3. LAD proximal 70% calcified stenosis present and patent stent to the mid LAD and diagonal 1 is a moderate-size vessel, has 70% stenosis. Left circumflex has diffuse luminal irregularities. OM1 has 70% stenosis, is a moderate-size vessel. Right coronary is dominant and has minimal luminal irregularities.,SUMMARY: , Three-vessel coronary artery disease with aortic stenosis by echo with normal pulmonary artery systolic pressure.,RECOMMENDATION: , Aortic valve replacement with coronary artery bypass surgery.

cardiovascular / pulmonary, lad proximal, femoral artery, sheath, catheter, selective coronary angiography, coronary artery disease, pulmonary capillary wedge, capillary wedge, coronary angiography, coronary artery, heart catheterization, catheterization, heart, artery, stenosis, angiography, pressure, coronary

Fogarty thrombectomy, left forearm arteriovenous Gore-Tex bridge fistula and revision of distal anastomosis with 7 mm interposition Gore-Tex graft. Chronic renal failure and thrombosed left forearm arteriovenous Gore-Tex bridge fistula.

Cardiovascular / Pulmonary

Fogarty Thrombectomy

PREOPERATIVE DIAGNOSES:,1. Chronic renal failure.,2. Thrombosed left forearm arteriovenous Gore-Tex bridge fistula.,POSTOPERATIVE DIAGNOSIS:,1. Chronic renal failure.,2. Thrombosed left forearm arteriovenous Gore-Tex bridge fistula.,PROCEDURE PERFORMED:,1. Fogarty thrombectomy, left forearm arteriovenous Gore-Tex bridge fistula.,2. Revision of distal anastomosis with 7 mm interposition Gore-Tex graft.,ANESTHESIA:, General with controlled ventillation.,GROSS FINDINGS: , The patient is a 58-year-old black male with chronic renal failure. He undergoes dialysis through the left forearm bridge fistula and has small pseudoaneurysms at the needle puncture sites level. There is narrowing at the distal anastomosis due to intimal hypoplasia and the vein beyond it was of good quality.,OPERATIVE PROCEDURE: , The patient was taken to the OR suite, placed in supine position. General anesthetic was administered. Left arm was prepped and draped in appropriate manner. A Pfannenstiel skin incision was created just below the antecubital crease just deeper to the subcutaneous tissue. Utilizing both blunt and sharp dissections segment of the fistula was isolated ________ vessel loop. Transverse graftotomy was created. A #4 Fogarty catheter passed proximally and distally restoring inflow and meager inflow. A fistulogram was performed and the above findings were noted. In a retrograde fashion, the proximal anastomosis was patent. There was no narrowing within the forearm graft. Both veins were flushed with heparinized saline and controlled with a vascular clamp. A longitudinal incision was then created in the upper arm just deep into the subcutaneous tissue fascia. Utilizing both blunt and sharp dissection, the brachial vein as well as distal anastomosis was isolated. The distal anastomosis amputated off the fistula and oversewn with continuous running #6-0 Prolene suture tied upon itself. The vein was controlled with vascular clamps. Longitudinal venotomy created along the anteromedial wall. A 7 mm graft was brought on to the field and this was cut to shape and size. This was sewed to the graft in an end-to-side fashion with U-clips anchoring the graft at the heel and toe with interrupted #6-0 Prolene sutures. Good backflow bleeding was confirmed. The vein flushed with heparinized saline and graft was controlled with vascular clamp. The end of the insertion graft was cut to shape in length and sutured to the graft in an end-to-end fashion with continuous running #6-0 Prolene suture. Good backflow bleeding was confirmed. The graftotomy was then closed with interrupted #6-0 Prolene suture. Flow through the fistula was permitted, a good flow passed. The wound was copiously irrigated with antibiotic solution. Sponge, needles, instrument counts were correct. All surgical sites were inspected. Good hemostasis was noted. The incision was closed in layers with absorbable sutures. Sterile dressing was applied. The patient tolerated the procedure well and returned to the recovery room in apparent stable condition.

cardiovascular / pulmonary, chronic renal failure, thrombosed, gore-tex bridge fistula, arteriovenous, fogarty, thrombectomy, anastomosis, gore tex bridge, fogarty thrombectomy, prolene suture, renal failure, distal anastomosis, bridge fistula, interposition, renal, prolene

H&P for a female with Angina pectoris.

Cardiovascular / Pulmonary

H&P - Cardio (Angina)

CHIEF COMPLAINT (1/1):, This 62 year old female presents today for evaluation of angina.,Associated signs and symptoms: Associated signs and symptoms include chest pain, nausea, pain radiating to the arm and pain radiating to the jaw.,Context: The patient has had no previous treatments for this condition.,Duration: Condition has existed for 5 hours.,Quality: Quality of the pain is described by the patient as crushing.,Severity: Severity of condition is severe and unchanged.,Timing (onset/frequency): Onset was sudden and with exercise. Patient has the following coronary risk factors: smoking 1 packs/day for 40 years and elevated cholesterol for 5 years. Patient's elevated cholesterol is not being treated with medication. Menopause occurred at age 53.,ALLERGIES:, No known medical allergies.,MEDICATION HISTORY:, Patient is currently taking Estraderm 0.05 mg/day transdermal patch.,PMH:, Past medical history unremarkable.,PSH:, No previous surgeries.,SOCIAL HISTORY:, Patient admits tobacco use She relates a smoking history of 40 pack years.,FAMILY HISTORY:, Patient admits a family history of heart attack associated with father (deceased).,ROS:, Unremarkable with exception of chief complaint.,PHYSICAL EXAMINATION:,General: Patient is a 62 year old female who appears pleasant, her given age, well developed,,oriented, well nourished, alert and moderately overweight.,Vital Signs: BP Sitting: 174/92 Resp: 28 HR: 88 Temp: 98.6 Height: 5 ft. 2 in. Weight: 150 lbs.,HEENT: Inspection of head and face shows head that is normocephalic, atraumatic, without any gross or neck masses. Ocular motility exam reveals muscles are intact. Pupil exam reveals round and equally reactive to light and accommodation. There is no conjunctival inflammation nor icterus. Inspection of nose reveals no abnormalities. Inspection of oral mucosa and tongue reveals no pallor or cyanosis. Inspection of the tongue reveals normal color, good motility and midline position. Examination of oropharynx reveals the uvula rises in the midline. Inspection of lips, teeth, gums, and palate reveals healthy teeth, healthy gums, no gingival,hypertrophy, no pyorrhea and no abnormalities.,Neck: Neck exam reveals neck supple and trachea that is midline, without adenopathy or crepitance palpable.,Thyroid examination reveals smooth and symmetric gland with no enlargement, tenderness or masses noted.,Carotid pulses are palpated bilaterally, are symmetric and no bruits auscultated over the carotid and vertebral arteries. Jugular veins examination reveals no distention or abnormal waves were noted. Neck lymph nodes are not noted.,Back: Examination of the back reveals no vertebral or costovertebral angle tenderness and no kyphosis or scoliosis noted.,Chest: Chest inspection reveals intercostal interspaces are not widened, no splinting, chest contours are normal and normal expansion. Chest palpation reveals no abnormal tactile fremitus.,Lungs: Chest percussion reveals resonance. Assessment of respiratory effort reveals even respirations without use of accessory muscles and diaphragmatic movement normal. Auscultation of lungs reveal diminished breath sounds bibasilar.,Heart: The apical impulse on heart palpation is located in the left border of cardiac dullness in the midclavicular line, in the left fourth intercostal space in the midclavicular line and no thrill noted. Heart auscultation reveals rhythm is regular, normal S1 and S2, no murmurs, gallop, rubs or clicks and no abnormal splitting of the second heart sound which moves normally with respiration. Right leg and left leg shows evidence of edema +6.,Abdomen: Abdomen soft, nontender, bowel sounds present x 4 without palpable masses. Palpation of liver reveals no abnormalities with respect to size, tenderness or masses. Palpation of spleen reveals no abnormalities with respect to size, tenderness or masses. Examination of abdominal aorta shows normal size without presence of systolic bruit.,Extremities: Right thumb and left thumb reveals clubbing.,Pulses: The femoral, popliteal, dorsalis, pedis and posterior tibial pulses in the lower extremities are equal and normal. The brachial, radial and ulnar pulses in the upper extremities are equal and normal. Examination of peripheral vascular system reveals varicosities absent, extremities warm to touch, edema present - pitting and pulses are full to palpation. Femoral pulses are 2 /4, bilateral. Pedal pulses are 2 /4, bilateral.,Neurological: Testing of cranial nerves reveals nerves intact. Oriented to person, place and time. Mood and affect normal and appropriate to situation.Deep tendon reflexes normal. Touch, pin, vibratory and proprioception sensations are normal. Babinski reflex is absent. Coordination is normal. Speech is not aphasic. Musculoskeletal: Muscle strength is 5/5 for all groups tested. Gait and station examination reveals midposition without abnormalities.,Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed. Skin is warm and dry with normal turgor and there is no icterus.,Lymphatics: No lymphadenopathy noted.,IMPRESSION:, Angina pectoris, other and unspecified.,PLAN:, ,DIAGNOSTIC & LAB ORDERS:, Ordered serum creatine kinase isoenzymes (CK isoenzymes). Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report. The following cardiac risk factor modifications are recommended: quit smoking and reduce LDL cholesterol to below 120 mg/dl.,PATIENT INSTRUCTIONS:

Chest pain and non-Q-wave MI with elevation of troponin I only. Left heart catheterization, left ventriculography, and left and right coronary arteriography.

Cardiovascular / Pulmonary

Heart Catheterization - 1

PROCEDURES: , Left heart catheterization, left ventriculography, and left and right coronary arteriography.,INDICATIONS: , Chest pain and non-Q-wave MI with elevation of troponin I only.,TECHNIQUE: ,The patient was brought to the procedure room in satisfactory condition. The right groin was prepped and draped in routine fashion. An arterial sheath was inserted into the right femoral artery.,Left and right coronary arteries were studied with a 6FL4 and 6FR4 Judkins catheters respectively. Cine coronary angiograms were done in multiple views.,Left heart catheterization was done using the 6-French pigtail catheter. Appropriate pressures were obtained before and after the left ventriculogram, which was done in the RAO view.,At the end of the procedure, the femoral catheter was removed and Angio-Seal was applied without any complications.,FINDINGS:,1. LV is normal in size and shape with good contractility, EF of 60%.,2. LMCA normal.,3. LAD has 20% to 30% stenosis at the origin.,4. LCX is normal.,5. RCA is dominant and normal.,RECOMMENDATIONS: , Medical management, diet, and exercise. Aspirin 81 mg p.o. daily, p.r.n. nitroglycerin for chest pain. Follow up in the clinic.

cardiovascular / pulmonary, arteriography, coronary arteriography, heart catheterization, ventriculography, angiograms

Flexible bronchoscopy to evaluate the airway (chronic wheezing).

Cardiovascular / Pulmonary

Flexible Bronchoscopy

PROCEDURE:, Flexible bronchoscopy.,PREOPERATIVE DIAGNOSIS (ES):, Chronic wheezing.,INDICATIONS FOR PROCEDURE:, Evaluate the airway.,DESCRIPTION OF PROCEDURE: ,This was done in the pediatric endoscopy suite with the aid of Anesthesia. The patient was sedated with sevoflurane and propofol. One mL of 1% lidocaine was used for airway anesthesia. The 2.8-mm flexible pediatric bronchoscope was passed through the left naris. The upper airway was visualized. The epiglottis, arytenoids, and vocal cords were all normal. The scope was passed below the cords. The subglottic space was normal. The patient had normal tracheal rings and a normal membranous portion of the trachea. There was noted to be slight deviation of the trachea to the right. At the carina, the right and left mainstem were evaluated. The right upper lobe, right middle lobe, and right lower lobe were all anatomically normal. The scope was wedged in the right middle lobe, 10 mL of saline was infused, 10 was returned. This was sent for cell count, cytology, lipid index, and quantitative bacterial cultures. The left side was then evaluated and there was noted to be the normal cardiac pulsations on the left. There was also noted to be some dynamic collapse of the left mainstem during the respiratory cycle. The left upper lobe and left lower lobe were normal. The scope was withdrawn. The patient tolerated the procedure well.,ENDOSCOPIC DIAGNOSIS:, Left mainstem bronchomalacia.

cardiovascular / pulmonary, flexible bronchoscopy, airway, arytenoids, bronchomalacia, bronchoscopy, endoscopy suite, epiglottis, mainstem, subglottic, vocal cords, wheezing, chronic wheezing, tracheal, lobe,

Flexible fiberoptic bronchoscopy with right lower lobe bronchoalveolar lavage and right upper lobe endobronchial biopsy. Severe tracheobronchitis, mild venous engorgement with question varicosities associated pulmonary hypertension, right upper lobe submucosal hemorrhage without frank mass underneath it status post biopsy.

Cardiovascular / Pulmonary

Flexible Fiberoptic Bronchoscopy

PREOPERATIVE/POSTOPERATIVE DIAGNOSES:,1. Severe tracheobronchitis.,2. Mild venous engorgement with question varicosities associated pulmonary hypertension.,3. Right upper lobe submucosal hemorrhage without frank mass underneath it status post biopsy.,PROCEDURE PERFORMED: , Flexible fiberoptic bronchoscopy with:,a. Right lower lobe bronchoalveolar lavage.,b. Right upper lobe endobronchial biopsy.,SAMPLES: , Bronchoalveolar lavage for cytology and for microbiology of the right lower lobe endobronchial biopsy of the right upper lobe.,INDICATIONS: , The patient with persistent hemoptysis of unclear etiology.,PROCEDURE: , After obtaining informed consent, the patient was brought to Bronchoscopy Suite. The patient had previously been on Coumadin and then heparin. Heparin was discontinued approximately one-and-a-half hours prior to the procedure. The patient underwent topical anesthesia with 10 cc of 4% Xylocaine spray to the left nares and nasopharynx. Blood pressure, EKG, and oximetry monitoring were applied and monitored continuously throughout the procedure. Oxygen at two liters via nasal cannula was delivered with saturations in the 90% to 100% throughout the procedure. The patient was premedicated with 50 mg of Demerol and 2 mg of Versed. After conscious sedation was achieved, the bronchoscope was advanced through the left nares into the nasopharynx and oropharynx. There was minimal redundant oral soft tissue in the oropharynx. There was mild erythema. Clear secretions were suctioned.,Additional topical anesthesia was applied to the larynx and then throughout the tracheobronchial tree for the procedure, a total of 16 cc of 2% Xylocaine was applied. Vocal cord motion was normal. The bronchoscope was then advanced through the larynx into the trachea. There was evidence of moderate inflammation with prominent vascular markings and edema. No frank blood was visualized. The area was suction clear of copious amounts of clear white secretions. Additional topical anesthesia was applied and the bronchoscope was advanced into the left main stem. The bronchoscope was then sequentially advanced into each segment and sub-segment of the left upper lobe and left lower lobe. There was significant amount of inflammation, induration, and vascular tortuosity in these regions. No frank blood was identified. No masses or lesions were identified. There was senile bronchiectasis with slight narrowing and collapse during the exhalation. The air was suctioned clear. The bronchoscope was withdrawn and advanced into the right main stem. Bronchoscope was introduced into the right upper lobe and each sub-segment was visualized. Again significant amounts of tracheobronchitis was noted with vascular infiltration. In the sub-carina of the anterior segment of the right upper lobe, there was evidence of a submucosal hematoma without frank mass underneath this. The bronchoscope was removed and advanced into the right middle and right lower lobe. There was marked injection and inflammation in these regions. In addition, there was marked vascular engorgement with near frank varicosities identified throughout the region. Again, white clear secretions were identified. No masses or other processes were noted. The area was suctioned clear. A bronchoalveolar lavage was subsequently performed in the anterior segment of the right lower lobe. The bronchoscope was then withdrawn and readvanced into the right upper lobe. Endobronchial biopsies of the carina of the sub-segment and anterior segment of the right upper lobe were obtained. Minimal hemorrhage occurred after the biopsy, which stopped after 1 cc of 1:1000 epinephrine. The area remained clear. No further hemorrhage was identified. The bronchoscope was subsequently withdrawn. The patient tolerated the procedure well and was stable throughout the procedure. No further hemoptysis was identified. The patient was sent to Recovery in good condition.

cardiovascular / pulmonary, bronchoalveolar lavage, endobronchial biopsy, cytology, microbiology, tracheobronchitis, venous engorgement, varicosities, pulmonary hypertension, flexible fiberoptic bronchoscopy, fiberoptic bronchoscopy, lobe, bronchoalveolar, lavage, endobronchial, hemorrhage, oropharynx, vascular, bronchoscopy, biopsy, submucosal, bronchoscope

Right and left heart catheterization, coronary angiography, left ventriculography.

Cardiovascular / Pulmonary

Heart Catheterization

PROCEDURES:,1. Right and left heart catheterization.,2. Coronary angiography.,3. Left ventriculography.,PROCEDURE IN DETAIL:, After informed consent was obtained, the patient was taken to the cardiac catheterization laboratory. Patient was prepped and draped in sterile fashion. Via modified Seldinger technique, the right femoral vein was punctured and a 6-French sheath was placed over a guide wire. Via modified Seldinger technique, right femoral artery was punctured and a 6-French sheath was placed over a guide wire. The diagnostic procedure was performed using the JL-4, JR-4, and a 6-French pigtail catheter along with a Swan-Ganz catheter. The patient tolerated the procedure well and there were immediate complications were noted. Angio-Seal was used at the end of the procedure to obtain hemostasis.,CORONARY ARTERIES:,LEFT MAIN CORONARY ARTERY: The left main coronary artery is of moderate size vessel with bifurcation into the left descending coronary artery and circumflex coronary artery. No significant stenotic lesions were identified in the left main coronary artery.,LEFT ANTERIOR DESCENDING CORONARY ARTERY: The left descending artery is a moderate sized vessel, which gives rise to multiple diagonals and perforating branches. No significant stenotic lesions were identified in the left anterior descending coronary artery system.,CIRCUMFLEX ARTERY: The circumflex artery is a moderate sized vessel. The vessel is a stenotic lesion. After the right coronary artery, the RCA is a moderate size vessel with no focal stenotic lesions.,HEMODYNAMIC DATA: , Capital wedge pressure was 22. The aortic pressure was 52/24. Right ventricular pressure was 58/14. RA pressure was 14. The aortic pressure was 127/73. Left ventricular pressure was 127/15. Cardiac output of 9.2.,LEFT VENTRICULOGRAM: , The left ventriculogram was performed in the RAO projection only. In the RAO projection, the left ventriculogram revealed dilated left ventricle with mild global hypokinesis and estimated ejection fraction of 45 to 50%. Severe mitral regurgitation was also noted.,IMPRESSION:,1. Left ventricular dilatation with global hypokinesis and estimated ejection fraction of 45 to 50%.,2. Severe mitral regurgitation.,3. No significant coronary artery disease identified in the left main coronary artery, left anterior descending coronary artery, circumflex coronary artery or the right coronary artery.,

cardiovascular / pulmonary, ventriculography, catheterization, seldinger, hypokinesis, estimated ejection fraction, severe mitral regurgitation, descending coronary artery, coronary artery, aortic pressure, heart catheterization, stenotic lesions, coronary, artery, heart, angiography, anterior, ventricular, ventriculogram, lesions

Fiberoptic flexible bronchoscopy with lavage, brushings, and endobronchial mucosal biopsies of the right bronchus intermedius/right lower lobe. Right hyoid mass, rule out carcinomatosis. Chronic obstructive pulmonary disease. Changes consistent with acute and chronic bronchitis.

Cardiovascular / Pulmonary

Fiberoptic Flexible Bronchoscopy

PREOPERATIVE DIAGNOSES:,1. Right hyoid mass, rule out carcinomatosis.,2. Weight loss.,3. Chronic obstructive pulmonary disease.,POSTOPERATIVE DIAGNOSES:,1. Right hyoid mass, rule out carcinomatosis.,2. Weight loss.,3. Chronic obstructive pulmonary disease.,4. Changes consistent with acute and chronic bronchitis.,5. Severe mucosal irregularity with endobronchial narrowing of the right middle and lower lobes.,6. Left vocal cord irregularity.,PROCEDURE PERFORMED: ,Fiberoptic flexible bronchoscopy with lavage, brushings, and endobronchial mucosal biopsies of the right bronchus intermedius/right lower lobe.,ANESTHESIA: , Demerol 50 mg with Versed 3 mg as well as topical cocaine and lidocaine solution.,LOCATION OF PROCEDURE: , Endoscopy suite #4.,After informed consent was obtained and following the review of the procedure including procedure as well as possible risks and complications were explained and consent was previously obtained, the patient was sedated with the above stated medication and the patient was continuously monitored on pulse oximetry, noninvasive blood pressure, and EKG monitoring. Prior to starting the procedure, the patient was noted to have a baseline oxygen saturation of 86% on room air. Subsequently, she was given a bronchodilator treatment with Atrovent and albuterol and subsequent saturation increased to approximately 90% to 91% on room air.,The patient was placed on a supplemental oxygen as the patient was sedated with above-stated medication. As this occurred, the bronchoscope was inserted into the right naris with good visualization of the nasopharynx and oropharynx. The cords were noted to oppose bilaterally on phonation. There was some slight mucosal irregularity noted on the vocal cord on the left side. Additional topical lidocaine was instilled on the vocal cords, at which point the bronchoscope was introduced into the trachea, which was midline in nature. The bronchoscope was then advanced to the distal trachea and additional lidocaine was instilled. At this time, the bronchoscope was further advanced through the main stem and additional lidocaine was instilled. Bronchoscope was then further advanced into the right upper lobe, which revealed no evidence of any endobronchial lesion. The mucosa was diffusely friable throughout. Bronchoscope was then slowly withdrawn into the right main stem and additional lidocaine was instilled. At this point, the bronchoscope was then advanced to the right bronchus intermedius. At this time, it was noted that there was severe mucosal irregularities of nodular in appearance significantly narrowing the right lower lobe and right middle lobe opening. The mucosal area throughout this region was severely friable. Additional lidocaine was instilled as well as topical epinephrine. At this time, bronchoscope was maintained in this region and endobronchial biopsies were performed. At the initial attempt of inserting biopsy forceps, some resistance was noted within the proximal channel at this time making advancement of the biopsy forceps out of the proximal channel impossible. So the biopsy forceps was withdrawn and the bronchoscope was completely withdrawn and new bronchoscope was then utilized. At this time, bronchoscope was then reinserted into the right naris and subsequently advanced to the vocal cords into the right bronchus intermedius without difficulty. At this time, the biopsy forceps were easily passed and visualized in the right bronchus intermedius. At this time, multiple mucosal biopsies were performed with some mild oozing noted. Several aliquots of normal saline lavage followed. After completion of multiple biopsies there was good hemostasis. Cytology flushing was also performed in this region and subsequently several aliquots of additional normal saline lavage was followed. Bronchoscope was unable to be passed distally to the base of the segment of the right lower lobe or distal to the further visualized endobronchial anatomy of the right middle lobe subsegments. The bronchoscope was then withdrawn to the distal trachea.,At this time, bronchoscope was then advanced to the left main stem. Additional lidocaine was instilled. The bronchoscope was advanced to the left upper and lower lobe subsegments. There was no endobronchial lesion visualized. There is mild diffuse erythema and fibromucosa was noted throughout. No endobronchial lesion was visualized in the left bronchial system. The bronchoscope was then subsequently further withdrawn to the distal trachea and readvanced into the right bronchial system. At this time, bronchoscope was readvanced into the right bronchus intermedius and additional aliquots of normal saline lavage until cleared. There is no gross bleeding evidenced at this time or diffuse mucosal erythema and edema present throughout. The bronchoscope was subsequently withdrawn and the patient was sent to recovery room. During the bronchoscopy, the patient noted ________ have desaturation and required increasing FiO2 with subsequent increased saturation to 93% to 94%. The patient remained at this level of saturation or greater throughout the remaining of the procedure.,The patient postprocedure relates having some intermittent hemoptysis prior to the procedure as well as moderate exertional dyspnea. This was confirmed by her daughter and mother who were also present at the bedside postprocedure. The patient did receive a nebulizer bronchodilator treatment immediately prebronchoscopy and postprocedure as well. The patient also admitted to continued smoking in spite of all of the above. The patient was extensively counseled regarding the continued smoking especially with her present symptoms. She was advised regarding smoking cessation. The patient was also placed on a prescription of prednisone 2 mg tablets starting at 40 mg a day decreasing every three days to continue to wean off. The patient was also administered Solu-Medrol 60 mg IV x1 in recovery room. There was no significant bronchospastic component noted, although because of the severity of the mucosal edema, erythema, and her complaints, short course of steroids will be instituted. The patient was also advised to refrain from using any aspirin or other nonsteroidal anti-inflammatory medication because of her hemoptysis. At this time, the patient was also advised that if hemoptysis were to continue or worsen or develop progressive dyspnea, to either contact myself, , or return to ABCD Emergency Room for evaluation of possible admission. However, the above was reviewed with the patient in great detail as well as with her daughter and mother who were at the bedsite at this time as well.

cardiovascular / pulmonary, carcinomatosis, chronic obstructive pulmonary disease, fiberoptic flexible bronchoscopy, lavage, brushings, endobronchial mucosal biopsies, mucosal, bronchoscope, atrovent, topical, fiberoptic, hemoptysis, bronchoscopy, endobronchial, oropharynx

Flexible fiberoptic bronchoscopy diagnostic with right middle and upper lobe lavage and lower lobe transbronchial biopsies. Mild tracheobronchitis with history of granulomatous disease and TB, rule out active TB/miliary TB.

Cardiovascular / Pulmonary

Flexible Fiberoptic Bronchoscopy -1

POSTOPERATIVE DIAGNOSIS:, Mild tracheobronchitis with history of granulomatous disease and TB, rule out active TB/miliary TB.,PROCEDURE PERFORMED:, Flexible fiberoptic bronchoscopy diagnostic with:,a. Right middle lobe bronchoalveolar lavage.,b. Right upper lobe bronchoalveolar lavage.,c. Right lower lobe transbronchial biopsies.,COMPLICATIONS:, None.,Samples include bronchoalveolar lavage of the right upper lobe and right middle lobe and transbronchial biopsies of the right lower lobe.,INDICATION: ,The patient with a history of TB and caseating granulomata on open lung biopsy with evidence of interstitial lung disease and question tuberculosis.,PROCEDURE:, After obtaining an informed consent, the patient was brought to the Bronchoscopy Suite with appropriate isolation related to ______ precautions. The patient had appropriate oxygen, blood pressure, heart rate, and respiratory rate monitoring applied and monitored continuously throughout the procedure. 2 liters of oxygen via nasal cannula was applied to the nasopharynx with 100% saturations achieved. Topical anesthesia with 10 cc of 4% Xylocaine was applied to the right nares and oropharynx. Subsequent to this, the patient was premedicated with 50 mg of Demerol and then Versed 1 mg sequentially for a total of 2 mg. With this, adequate consciousness sedation was achieved. 3 cc of 4% viscous Xylocaine was applied to the right nares. The bronchoscope was then advanced through the right nares into the nasopharynx and oropharynx.,The oropharynx and larynx were well visualized and showed mild erythema, mild edema, otherwise negative.,There was normal vocal cord motion without masses or lesions. Additional topical anesthesia with 2% Xylocaine was applied to the larynx and subsequently throughout the tracheobronchial tree for a total of 18 cc. The bronchoscope was then advanced through the larynx into the trachea. The trachea showed mild evidence of erythema and moderate amounts of clear frothy secretions. These were suctioned clear. The bronchoscope was then advanced through the carina, which was sharp. Then advanced into the left main stem and each segment, subsegement in the left upper lingula and lower lobe was visualized. There was mild tracheobronchitis with mild friability throughout. There was modest amounts of white secretion. There were no other findings including evidence of mass, anatomic distortions, or hemorrhage. The bronchoscope was subsequently withdrawn and advanced into the right mainstem. Again, each segment and subsegment was well visualized. The right upper lobe anatomy showed some segmental distortion with dilation and irregularities both at the apical region as well as in the subsegments of the anteroapical and posterior segments. No specific masses or other lesions were identified throughout the tracheobronchial tree on the right. There was mild tracheal bronchitis with friability. Upon coughing, there was punctate hemorrhage. The bronchoscope was then advanced through the bronchus intermedius and the right middle lobe and right lower lobe. These again had no other anatomic lesions identified. The bronchoscope was then wedged in the right middle lobe and bronchoalveolar samples were obtained. The bronchoscope was withdrawn and the area was suctioned clear. The bronchoscope was then advanced into the apical segment of the right upper lobe and the bronchioalveolar lavage again performed. Samples were taken and the bronchoscope was removed suctioned the area clear. The bronchoscope was then re-advanced into the right lower lobe and multiple transbronchial biopsies were taken under fluoroscopic guidance in the posterior and lateral segments of the right lower lobe. Minimal hemorrhage was identified and suctioned clear without difficulty. The bronchoscope was then withdrawn to the mainstem. The area was suctioned clear. Fluoroscopy revealed no evidence of pneumothorax. The bronchoscope was then withdrawn. The patient tolerated the procedure well without evidence of desaturation or complications.

cardiovascular / pulmonary, bronchoalveolar, lavage, lobe, tracheobronchitis, granulomatous, miliary tb, tb, flexible fiberoptic bronchoscopy, bronchoscope, flexible, fiberoptic, transbronchial, biopsies, bronchoscopy, oropharynx,

Left arm fistulogram. Percutaneous transluminal angioplasty of the proximal and distal cephalic vein. Ultrasound-guided access of left upper arm brachiocephalic fistula.

Cardiovascular / Pulmonary

Fistulogram & Angioplasty

PREPROCEDURE DIAGNOSIS: , End-stage renal disease.,POSTPROCEDURE DIAGNOSIS: , End-stage renal disease.,PROCEDURES PERFORMED,1. Left arm fistulogram.,2. Percutaneous transluminal angioplasty of the proximal and distal cephalic vein.,3. Ultrasound-guided access of left upper arm brachiocephalic fistula.,ANESTHESIA:, Sedation with local.,COMPLICATIONS:, None.,CONDITION:, Fair.,DISPOSITION:, PACU.,ACCESS SITE:, Left upper arm brachiocephalic fistula.,SHEATH SIZE: , 5 French.,CONTRAST TYPE: , JC PEG tube 70.,CONTRAST VOLUME: , 48 mL.,FLUOROSCOPY TIME: , 16 minutes.,INDICATION FOR PROCEDURE: , This is a 38-year-old female with a left upper arm brachiocephalic fistula which has been transposed. The patient recently underwent a fistulogram with angioplasty at the proximal upper arm cephalic vein due to a stenosis detected on Duplex ultrasound. The patient subsequently was noted to have poor flow to the fistula, and the fistula was difficult to palpate. A repeat ultrasound was performed which demonstrated a high-grade stenosis involving the distal upper arm cephalic vein just distal to the brachial anastomosis. The patient presents today for a left arm fistulogram with angioplasty. The risks, benefits, and alternatives of the procedure were discussed with the patient and understands and in agreement to proceed.,PROCEDURE DETAILS: ,The patient was brought to the angio suite and laid supine on the table. After sedation was administered, the left arm was then prepped and draped in a standard surgical fashion. Continuous pulse oximetry and cardiac monitoring were performed throughout the procedure. The patient was given 1 g of IV Ancef prior to incision.,The left brachiocephalic fistula was visualized with bevel ultrasound. The cephalic vein in the proximal upper arm region appeared to be of adequate caliber. There was an area of stenosis at the proximal cephalic vein just distal to the brachial artery anastomosis. The cephalic vein in the proximal forearm region was easily compressible. The skin overlying the vessel was injected with 1% lidocaine solution. A small incision was made with the #11 blade. The cephalic vein then was cannulated with a 5 French micropuncture introducer sheath. The sheath was advanced over the wire. A fistulogram was performed which demonstrated a high-grade stenosis just distal to the brachial artery anastomosis. The introducer sheath was then exchanged for a 5 French sheath over a 0.025 guide wire. The sheath was aspirated and flushed with heparinized saline solution. A 0.025 glidewire was then obtained and advanced, placed over the sheath and across the area of stenosis into the brachial artery. A 5 French short Kumpe catheter was used to guide the wire into the distal brachial and radial artery. After crossing the area of stenosis, a 5 x 20 mm standard angioplasty balloon was obtained and prepped from the back table. This was placed over the glidewire into the area of stenosis and inflated to 14 mmHg pressure and then deflated. The balloon was then removed over the wire and repeat fistulogram was performed which demonstrated significant improvement. However, there is still a remainder of residual stenosis. The 5-mm balloon was placed over the wire again and a repeat angioplasty was performed. The balloon was then removed over the wire and a repeat angiogram was performed which demonstrated again an area of stenosis right at the anastomosis. The glidewire was removed and a 0.014 guide wire was then obtained and placed through the sheath and across the brachial anastomosis and into the radial artery. A 4 x 20 mm cutting balloon was obtained and prepped on the back table. The 5 French sheath was then exchanged for a 6 French sheath. The balloon was then placed over the 0.014 guide wire into the area of stenosis and then inflated to normal pressures at 8 mmHg. The balloon was then deflated and removed over the wire. A 5 mm x 20 mm balloon was obtained and prepped and placed over the wire into the area of stenosis and inflated to pressures of 14 mmHg. A repeat fistulogram was performed after the removal of the balloon which demonstrated excellent results with no significant residual stenosis. The patient actually had a nice palpable thrill at this point. The fistulogram of the distal cephalic vein at the subclavian anastomosis was performed which demonstrated a mild area of stenosis. The sheath was removed and blood pressure was held over the puncture site for approximately 10 minutes.,After hemostasis was achieved, the cephalic vein again was visualized with bevel ultrasound. The proximal cephalic vein was then cannulated after injecting the skin overlying the vessel with a 1% lidocaine solution. A 5 French micropuncture introducer sheath was then placed over the wire into the proximal cephalic vein. A repeat fistulogram was performed which demonstrated an area of stenosis within the distal cephalic vein just prior to the subclavian vein confluence. The 5 French introducer sheath was then exchanged for a 5 French sheath. The 5 mm x 20 mm balloon was placed over a 0.035 glidewire across the area of stenosis. The balloon was inflated to 14 mmHg. The balloon was then deflated and a repeat fistulogram was performed through the sheath which demonstrated good results. The sheath was then removed and blood pressure was held over the puncture site for approximately 10 minutes. After adequate hemostasis was achieved, the area was cleansed in 2x2 and Tegaderm was applied. The patient tolerated the procedure without any complications. I was present for the entire case. The sponge, instrument, and needle counts are correct at the end of the case. The patient was subsequently taken to PACU in stable condition.,ANGIOGRAPHIC FINDINGS:, The initial left arm brachiocephalic fistulogram demonstrated a stenosis at the brachial artery anastomosis and distally within the cephalic vein. After standard balloon angioplasty, there was a mild improvement but some residual area of stenosis remained at the anastomosis. Then postcutting balloon angioplasty, venogram demonstrated a significant improvement without any evidence of significant stenosis.,Fistulogram of the proximal cephalic vein demonstrated a stenosis just prior to the confluence with the left subclavian vein. Postangioplasty demonstrated excellent results with the standard balloon. There was no evidence of any contrast extravasation.,IMPRESSION,1. High-grade stenosis involving the cephalic vein at the brachial artery anastomosis and distally. Postcutting balloon and standard balloon angioplasty demonstrated excellent results without any evidence of contrast extravasation.,2. A moderate grade stenosis within the distal cephalic vein just prior to the confluence to the left subclavian vein. Poststandard balloon angioplasty demonstrated excellent results. No evidence of contrast extravasation.