Atrial fibrillation Acute on chronic diastolic heart failure Sinoatrial node dysfunction Chronic total occlusion of coronary artery Diabetes mellitus without mention of complication type II or unspecified type not stated as uncontrolled Long-term (current) use of insulin Congestive heart failure unspecified Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Mitral valve disorders Other and unspecified angina pectoris Long-term (current) use of anticoagulants Other specified forms of chronic ischemic heart disease Nontoxic multinodular goiter
 
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
Morphine / Indocin / Nafcillin
 
Attending: ___.
 
Chief Complaint:
SOB
A-fib with RVR
 
Major Surgical or Invasive Procedure:
None

 
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of ischemic 
cardiomyopathy EF ___, CAD (2VD with chronic total 
occlusions), tachy-brady syndrome, A-fib initially evaluated at 
the ___. She is now being transferred for exertional RVR 
that was difficult to control with escalating doses of of beta 
blockade for consideunstable angina who presented to ___ 
with unstable angina. Per report, she has a history of unstable 
angina for which she takes nitroglycerin, and took 3 doses prior 
to presentation toration of PPM or AICD (given low EF). Her 
hospital course was notable for decompensated systolic heart 
failure and her lasix was increased from her home dose of 60 mg 
daily to 80 mg daily. ECHO at ___ revealed EF ___ with 
multiple regional wall motion abnormalities. Her metoprolol was 
increased from 100mg XL daily to 100 mg BID, though HR still 
escalate to 130s with any exertion and sustained. Coumadin was 
held at ___ in case any procedures are planned. Of note, her 
long acting nitrates were recently discontinued by her 
outpatient cardiologist. 

Vitals on transfer: 97.4 HR 72 ___nd 130 w/ movement, resp 
___, 133/66, 97% ra.  
 
On review of systems, s/he denies any prior history of stroke, 
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the 
time of surgery, myalgias, joint pains, cough, hemoptysis, black 
stools or red stools. S/he denies recent fevers, chills or 
rigors. S/he denies exertional buttock or calf pain. All of the 
other review of systems were negative.  
 
Cardiac review of systems is notable for absence of chest pain, 
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, 
ankle edema, palpitations, syncope or presyncope.  
 
Past Medical History:
1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Hypertension
2. CARDIAC HISTORY:
# Atrial fibrillation (on coumadin)
# Coronary artery disease
# ___ with EF 40%
-PERCUTANEOUS CORONARY INTERVENTIONS: cardiac catheterization at
___ in ___ showing "small vessel disease", cardiac cath in 
___ showing two vessel disease without any intervention
3. OTHER PAST MEDICAL HISTORY:
# History of Non-Hodgkin's lymphoma
# Multinodular Goiter
# Chronic Low Back Pain
# s/p hysterectomy
# s/p bilateral knee replacements
# s/p bilateral eye surgery
 
Social History:
___
Family History:
Diabetes; Grandmother died of MI at ___. Father: MI in ___, 
Mother: died before her ___ of "heart condition that was 
undiagnosed"
 
Physical Exam:
General:  elderly female resting in bed, NAD
HEENT:  NCAT, scleric anicterus
Neck:  Elevated JVP 7cm above sternal angle. Neck supple
CV:  Irregularly irregular. Normal S1/S2, no murmurs.
Lungs:  CTABL
Abdomen:  soft, NT/ND
Ext:  Warm, dry. No ___:  alert, oriented
PULSES:  1+ peripheral pulse.
 
Pertinent Results:
___ 04:53AM BLOOD WBC-7.7 RBC-4.33 Hgb-12.6 Hct-38.1 MCV-88 
MCH-29.2 MCHC-33.1 RDW-14.7 Plt ___
___ 04:53AM BLOOD Glucose-145* UreaN-27* Creat-1.4* Na-143 
K-3.6 Cl-103 HCO3-28 AnGap-16
___ 04:53AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.___-fib with RVR: ___ with ischemic cardiomyopathy EF ___, 
CAD with 2VD with chronic total occlusion, tachy-brady syndrome, 
and A-fib who was transferred to ___ from ___ for 
exertional RVR that was difficult to control with high dose 
beta-blockers, decompensated CHF, and evaluation for potential 
pacemaker.

Her metoprolol XL was recently increased from 100mg daily to 
100mg BID at the OSH. Her heart rate remained well-controll <100 
during her hospitalization at ___ even with ambulation. We 
ultimately adjusted her metoprolol XL to 150mg daily. Her HR and 
BP remained under well-controlled on this new dosage.

At this time, pacemaker is not warranted as her HR is 
well-controlled with pharmacologic agents. Her coumadin was 
restarted and INR was in therapeutic range prior to discharge. 

___ pharmacist reviewed patient's medications prior to 
discharge.

# CHF exacerbation: Pt's SOB is partly contributed by volume 
overload ___ ischemic cardiomyopathy. Her home lasix was 
increased from 40mg BID to 80mg BID. Lytes remained stable prior 
to discharge.
 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clopidogrel 75 mg PO DAILY 
2. Digoxin 0.125 mg PO DAILY 
3. Gabapentin 300 mg PO BID 
4. Metoprolol Succinate XL 100 mg PO DAILY 
5. Nitroglycerin SL 0.4 mg SL PRN Chest pain 
6. Pantoprazole 40 mg PO Q24H 
7. Simvastatin 20 mg PO DAILY 
8. Losartan Potassium 50 mg PO DAILY 
9. Percocet (oxyCODONE-acetaminophen) 7.5-325 mg ORAL TID:PRN 
pain 
10. Furosemide 40 mg PO DAILY 
11. Warfarin 5 mg PO DAILY16 Atrial fibrillation 
12. Detemir 40 Units Breakfast
Detemir 12 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
13. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath 
14. Potassium Chloride 10 mEq PO DAILY 
15. Aspirin 81 mg PO DAILY 
16. Vitamin D 1000 UNIT PO DAILY 
17. Docusate Sodium 100 mg PO BID 
18. Senna 17.2 mg PO DAILY 

 
Discharge Medications:
1. Aspirin 81 mg PO DAILY 
2. Clopidogrel 75 mg PO DAILY 
3. Digoxin 0.125 mg PO DAILY 
4. Furosemide 80 mg PO BID 
RX *furosemide 80 mg 1 tablet(s) by mouth twice daily Disp #*60 
Tablet Refills:*3
5. Losartan Potassium 50 mg PO DAILY 
6. Metoprolol Succinate XL 150 mg PO DAILY 
RX *metoprolol succinate 100 mg 1.5 tablet(s) by mouth once 
daily Disp #*45 Tablet Refills:*3
7. Pantoprazole 40 mg PO Q24H 
8. Warfarin 5 mg PO DAILY16 Atrial fibrillation 
9. Atorvastatin 80 mg PO QPM 
RX *atorvastatin 80 mg 1 tablet(s) by mouth once nightly Disp 
#*30 Tablet Refills:*3
10. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath 
11. Docusate Sodium 100 mg PO BID 
12. Nitroglycerin SL 0.4 mg SL PRN Chest pain 
13. Percocet (oxyCODONE-acetaminophen) 7.5-325 mg ORAL TID:PRN 
pain 
14. Potassium Chloride 10 mEq PO DAILY 
Hold for K > 4.5 
15. Senna 17.2 mg PO DAILY 
16. Vitamin D 1000 UNIT PO DAILY 
17. Detemir 40 Units Breakfast
Detemir 12 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
18. Gabapentin 300 mg PO BID 

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
A-fib, heart rate controlled
Decompensated CHF

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker 
or cane).

 
Discharge Instructions:
Ms ___:

It was a pleasure taking care of you. You were transferred to us 
from ___ due to fast heart rate associated with 
your A-fib and for evaluation of potential pacemaker. 

You were monitored on a continuous heart monitor during 
hospitalization, which revealed that your heart rate was very 
well-controlled with the new dose of metoprolol (150mg daily). 
We reviewed your studies very carefully and determine that a 
pacemaker will NOT be beneficial at this time. 

Your coumadin was held at the outside hospital in anticipation 
for potential procedure. You were restarted on coumadin at ___ 
___ and your INR was in therapeutic range prior to discharge.

For your shortness of breath, we believe it is due to volume 
overload secondary to decompensated heart failure. You will be 
discharged on a higher dose of lasix. Please Weigh yourself 
every morning, call MD if weight goes up more than 3 lbs.

 
Followup Instructions:
___

{'SOB': ['Atrial fibrillation', 'Acute on chronic diastolic heart failure', 'Congestive heart failure', 'unspecified', 'Coronary atherosclerosis of native coronary artery', 'Unspecified essential hypertension', 'Mitral valve disorders', 'Other and unspecified angina pectoris', 'Long-term (current) use of anticoagulants', 'Other specified forms of chronic ischemic heart disease'], 'A-fib with RVR': ['Atrial fibrillation', 'Acute on chronic diastolic heart failure', 'Congestive heart failure', 'unspecified', 'Coronary atherosclerosis of native coronary artery', 'Unspecified essential hypertension', 'Mitral valve disorders', 'Other and unspecified angina pectoris', 'Long-term (current) use of anticoagulants', 'Other specified forms of chronic ischemic heart disease'], 'Decompensated CHF': ['Acute on chronic diastolic heart failure', 'Congestive heart failure', 'unspecified', 'Coronary atherosclerosis of native coronary artery', 'Unspecified essential hypertension', 'Mitral valve disorders', 'Other and unspecified angina pectoris', 'Long-term (current) use of anticoagulants', 'Other specified forms of chronic ischemic heart disease']}