DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
ADMITTING DIAGNOSES:
1. Congestive heart failure.
2. Diabetes mellitus.
3. Pulmonary hypertension.
4. Worsening shortness of breath.
DISCHARGE DIAGNOSES:
1. Congestive heart failure.
2. Status post left ventricular assist device.
3. Status post heart transplant.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old gentleman with a history of an enlarged heart, per him, and diabetes mellitus. He was recently discharged; however, he developed worsening shortness of breath. He was instructed to present to the hospital for further evaluation and treatment. After being evaluated, admission was recommended.
ADMISSION MEDICATIONS: Protonix, Coumadin, Lipitor, Primacor, insulin, Coreg, Demadex, allopurinol, aspirin, potassium, and spironolactone.
PHYSICAL EXAMINATION: GENERAL: Examination upon admission revealed a (XX)-year-old pleasant Hispanic male, alert, cooperative and oriented x3. SKIN: Warm and dry. NECK: Supple. Jugular venous distention was not reported. CHEST: Chest expansion was symmetric. LUNGS: Clear. CARDIAC: Examination revealed neither S3 nor S4. ABDOMEN: Soft, flat, nontender. A PICC was present. EXTREMITIES: There was 1+ bilateral lower extremity edema. NEUROLOGIC: Exam was grossly normal.
HOSPITAL COURSE: The patient was admitted to the medical center. A Swan-Ganz catheter was placed. Primacor and Natrecor were begun. Routine laboratory studies were obtained. The hemodynamic data demonstrated significant pulmonary hypertension with an elevated pulmonary vascular resistance. He was maintained on intravenous Primacor and Natrecor. Unfortunately, his general condition began to deteriorate. The possibility of a left ventricular assist device was considered in late April or early May. On MM/DD/YYYY, the HeartMate vented electric system was implanted by Dr. John Doe. After a difficult early postoperative course, the patient’s condition improved.
The patient was transferred from the cardiothoracic intensive care unit to the step-down unit. Rehabilitation was begun. The patient’s medication doses were adjusted. Arrangements were made for the patient to be discharged to home. One day prior to discharge, however, a donor heart was identified. He was taken back to the operating room, and heart transplant was performed. The cross-clamp time was 230 minutes.
The post-transplant course was relatively uneventful. The patient was started on triple drug immunosuppression. His intravenous inotropes were weaned. The chest tubes were withdrawn. Post-transplant/pre-discharge education was provided, and the patient was discharged to home in stable condition.
DISCHARGE MEDICATIONS: Protonix, prednisone, ganciclovir, MMF, nystatin, Prograf, Cozaar, Carafate, Lasix, magnesium, and Avandia.
Of note, the patient received CMV-positive donor. The patient himself was CMV negative. For this reason, he was treated with CytoGam and ganciclovir. As well, the patient was hepatitis B core antibody positive. For this reason, the patient received HBIg. He was also started on adefovir. The patient’s first endomyocardial biopsy was clean. The patient’s next biopsy will be performed on MM/DD/YYYY. Followup will take place at the office.
