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Hey guys heres a case.
65 y.o. 77kg, 5'11" BMI 23, with previous medical history of CAD, MI x3 (last in 2017); s/p DES to OM (6/07); periprocedure thalamic CVA x 2 with right-sided weakness; s/p CABG (LIMA-LAD, SVG-RCA/PDA in 4/2010) and DES x4 (OM1 6/2017, LAD 5/2008 and 2017, LCx 5/2015) with ischemic cardiomyopathy, h/o VT and CHB s/p AICD (pacemaker dependent); infected AICD, lead extraction 4/26/2019 and generator change with leadless single chamber pacemaker; chronic stable angina, OSA (on home CPAP) and syncope. From SNG for acute right leg pain after falling out of his wheelchair. Found to have Comminuted fracture of the proximal femur metadiaphysis, with displacement and overriding of the fragments
Plan for open reduction internal fixation, IM nail fixation (R) Hip.
Echocardiogram: Date: 10/23/19
LV ejection fraction (%): 20
Valve Assessment
mild aortic insufficiency
moderate mitral regurgitation
moderate tricuspid regurgitation
Pulmonary Pressure (mmHg): 55, Moderate Pulm Htn
Other: CONCLUSIONS
1. Definity contrast agent was given intravenously to enhance visualization.
2. Mildly increased left ventricular size.
3. Borderline concentric left ventricular hypertrophy.
4. There are no normally-contracting wall segments.
5. The calculated ejection fraction (Simpson's) is 20 %.
6. Upper normal right ventricle in size.
7. Moderately reduced RV systolic function.
8. Severely dilated left atrium in size.
9. Moderately dilated right atrium in size.
10. At least moderate mitral valve regurgitation. If clinically indicated and if management of a patient will alter, a transesophageal echocardiogram (TEE) may be considered.
11. Moderate tricuspid regurgitation.
12. Mild aortic regurgitation.
13. Moderately elevated PA systolic pressure.
14. Elevated right-sided filling pressure.
CT Chest yesterday:
IMPRESSION:
1. Interval development of peripheral lobulated masslike consolidation within the left lower lobe/lingula, small to moderate left pleural effusion and prominent mediastinal lymph nodes. This raises concern for malignancy/lung cancer. Recommend further
evaluation with contrast-enhanced CT and/or, left pleural fluid analysis or lung biopsy depending on clinical scenario.
2. Nodular consolidative opacities in the right lung apex are of indeterminate etiology. Possibility include infection or malignancy
3. Scattered areas of airways impaction, most prominently in the right lower lobe, likely aspiration.
4. Cardiomegaly. Coronary stents. Leadless ICD in the right ventricle
Hgb 10.1
BNP 4.4k
Creatinine 1.22
INR 1.3
This being done at an ortho hospital without intraop TEE. There is a cath lab.
Epidural, a line, central line w/ MAC? General with preinduction a line, central line w/ PAC? What would you guys do? Thanks ahead of time.
65 y.o. 77kg, 5'11" BMI 23, with previous medical history of CAD, MI x3 (last in 2017); s/p DES to OM (6/07); periprocedure thalamic CVA x 2 with right-sided weakness; s/p CABG (LIMA-LAD, SVG-RCA/PDA in 4/2010) and DES x4 (OM1 6/2017, LAD 5/2008 and 2017, LCx 5/2015) with ischemic cardiomyopathy, h/o VT and CHB s/p AICD (pacemaker dependent); infected AICD, lead extraction 4/26/2019 and generator change with leadless single chamber pacemaker; chronic stable angina, OSA (on home CPAP) and syncope. From SNG for acute right leg pain after falling out of his wheelchair. Found to have Comminuted fracture of the proximal femur metadiaphysis, with displacement and overriding of the fragments
Plan for open reduction internal fixation, IM nail fixation (R) Hip.
Echocardiogram: Date: 10/23/19
LV ejection fraction (%): 20
Valve Assessment
mild aortic insufficiency
moderate mitral regurgitation
moderate tricuspid regurgitation
Pulmonary Pressure (mmHg): 55, Moderate Pulm Htn
Other: CONCLUSIONS
1. Definity contrast agent was given intravenously to enhance visualization.
2. Mildly increased left ventricular size.
3. Borderline concentric left ventricular hypertrophy.
4. There are no normally-contracting wall segments.
5. The calculated ejection fraction (Simpson's) is 20 %.
6. Upper normal right ventricle in size.
7. Moderately reduced RV systolic function.
8. Severely dilated left atrium in size.
9. Moderately dilated right atrium in size.
10. At least moderate mitral valve regurgitation. If clinically indicated and if management of a patient will alter, a transesophageal echocardiogram (TEE) may be considered.
11. Moderate tricuspid regurgitation.
12. Mild aortic regurgitation.
13. Moderately elevated PA systolic pressure.
14. Elevated right-sided filling pressure.
CT Chest yesterday:
IMPRESSION:
1. Interval development of peripheral lobulated masslike consolidation within the left lower lobe/lingula, small to moderate left pleural effusion and prominent mediastinal lymph nodes. This raises concern for malignancy/lung cancer. Recommend further
evaluation with contrast-enhanced CT and/or, left pleural fluid analysis or lung biopsy depending on clinical scenario.
2. Nodular consolidative opacities in the right lung apex are of indeterminate etiology. Possibility include infection or malignancy
3. Scattered areas of airways impaction, most prominently in the right lower lobe, likely aspiration.
4. Cardiomegaly. Coronary stents. Leadless ICD in the right ventricle
Hgb 10.1
BNP 4.4k
Creatinine 1.22
INR 1.3
This being done at an ortho hospital without intraop TEE. There is a cath lab.
Epidural, a line, central line w/ MAC? General with preinduction a line, central line w/ PAC? What would you guys do? Thanks ahead of time.