CHIEF COMPLAINT: Heart failure. Coronary artery disease. Atrial flutter.
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This patient had an acute MI _____ and underwent three vessel coronary artery bypass grafting at that time. He states he had a cardiac catheterization elsewhere about four years ago and they did not perform any intervention at that time. He has had a transthoracic echocardiography and stress nuclear imaging test that has shown EF of 40%. His last nuclear imaging test showed only mild inferior ischemia and fixed LAD infarct 01/04/2017.
The patient was admitted to Granville Hospital 01/11/2017 with heart failure and at that time the EF was stated to be 25-30%.
He has been in intermittent atrial flutter for some time. The chart says that he has had atrial fibrillation but the only ECGs I can find were where his SVT show atrial flutter with a controlled ventricular response.
Patient states he has gained about 25 pounds in the last two months. Certainly, he has gained 25 pounds since 08/24/2016 when he weighed 326 pounds. He did not have any significant heart failure in August. Last creatinine in the records was 1.7. Last ECG shows atrial flutter. Last sodium 131, potassium 5.0, but blood sugar was 589 and his hemoglobin A1c was 12.8, his LDL 69. REVIEW OF SYSTEMS Positive for not being able to lie down flat because of shortness of breath, peripheral edema, and exertional shortness of breath. He has diabetic neuropathy. He does not follow a diabetic diet. He has been having chest pain for about two years requiring sublingual nitroglycerin. Sublingual nitroglycerin relieves the discomfort within minutes. If he does not take the nitroglycerin it takes up to 30 minutes to relieve the discomfort. He takes nitroglycerin about once to twice per week. The only thing that consistently brings on the chest discomfort is being emotionally upset. He has not noticed that physical activity brings on the chest discomfort. He is, however, very physically active. His pertinent meds include aspirin and digoxin 0.125 mg every day, furosemide 80 mg, insulin isosorbide 60 mg daily, losartan 25, metformin a 1000 twice a day, metoprolol-XL 25 mg, sublingual nitroglycerin, potassium, and warfarin. PHYSICAL EXAMINATION His weight was 349. His blood pressure sitting was 96 systolic and standing up was 110. Pulse was 94, regular. Afebrile. Respirations 22, O2 saturation 95%. I observed him in the waiting room and he kept falling asleep …show more content…
He is too fluid overloaded to tolerate cardiac catheterization at this time. Please set up a followup appointment with Cardiology Clinic after a month when he has lost 10 pounds so we consider cardiac catheterization.
4. Please order a 24 or 48-hour Holter monitor so we can look at the atrial flutter burden but also determine whether he is going in and out of atrial fib, atrial flutter. If he only has atrial flutter then we could consider an atrial flutter ablation.
5. Weight loss and low-salt low-carb diet were discussed with the patient at length and the critical importance of using his CPAP machine every time he goes to sleep. 6. If you cannot obtain adequate diuresis with p.o. diuretics you may have to use IV diuretics. If that is unsuccessful he will need to be hospitalized at Duke Regional Hospital for IV diuresis and tune-up for cardiac catheterization and possible atrial flutter ablation.
7. Consider using something other than metformin for diabetic control because of the concomitant heart