心臟外科標準病歷範本-Admission Note
Case 1: Peripheral arterial occlusive disease
Chief complaint:
Right foot and toes poor wound healing for three weeks.
Present Illness:
This 68 y/o female had history of: 1. Type II DM with insulin control for more 10 years; 2.
Hypertension without regular control for several years; 3. Coronary artery disease with triple
vessels disease s/p coronary artery bypass graft on 08/23/2008; 4. End stage renal disease on regular
hemodialysis.
According to her, she suffered the painful right foot and toes for 3 weeks ago. At first, pain and
discharge from the big toe were discerned. Therefore, she went to our ER and the big toe nail was
removed. But the pain and poor healing of the wound were perceived. Three days ago, she went to
our ER again and was referred to our CVS OPD where the physical examination revealed: dry
gangrenous right big toe with tenderness over the lateral side; absent pulses of the right dorsalis
pedis artery and posterior tibial artery; the shiny skin on the leg; no fever, weakness, and
claudication. For peripheral arterial occlusive disease of the right lower limb, she was admitted for
further treatment.
Throughout the whole course, there was no fever, chills, nausea, vomiting, shortness of breath,
chest pain, or bloody stool passage. He denied taking recent: analgesics; steroids; herbs.
Impression:
1. Peripheral arterial occlusive disease of right lower limb
Plans:
(1) Diagnostic plan:
Arrange ABI and angiography for further evaluation
(2) Therapeutic plan:
1. Bypass surgery or PTA will be arranged if artery occlusion or stenosis.
2. Wound care and antibiotic treatment.
3. PGE1 prescribed.
(3) Educational plan:
1. Wound care and possible of toe amputation if surgery and medical treatment failure.
2. Post-op rehabilitation
Case 2: Varicose vein
Chief complaint:
Tortuous superficial vein and painful of bilateral low extremities for five years
Present Illness:
According to the 72-year-old woman and previous chart, she had the superficial vein engorgement
in bilateral lower extremities for five years. Nevertheless, she paid no attention to it due to
insignificant discomfort. Three months ago, she suffered much local tenderness and heat of these
tortuous superficial veins and night cramping pain, so she visited CVS OPD. The physical
examination evidenced skin color changes, no venous stasis, no leg swelling, no deep seated aching,
and no stasis ulcer. The varicose veins of the bilateral leg were impressed. After surgical risk and
procedure well explained, she was admitted for surgical intervention and additional administration.
Throughout the whole course, there was no surgery history, no fever, chills, nausea, vomiting,
shortness of breath, and chest pain. She denied taking recent: analgesics; steroids; herbs.
Impression:
Varicose vein of bilateral leg
Plans:
1. Diagnostic plan:
Arrange lower limbs venous echography for further evaluation
2. Therapeutic plan:
Strippling & linton’s operation operation will be performed.
3. Educational plan:
1. Possible of the complication of the operation, including deep vein thrombosis, pulmonary
emboli.
2. Post-op bed rest and lower bilateral leg protected with elastic bandage for three months
Case 3: Ventricular septal defect
Chief complaint:
Dyspnea after climbing a floor for two weeks
Present illness
This 29 year-old female who was diagnosed Type II VSD at KSCGH when 15 had: no regular
follow up; dyspnea this time after taking the stairs; palpitation and chest discomfort for 3 weeks.
She came to our CV OPD which: observed grade IV systolic murmur, no gallop, and no pitting
edema; arranged serial examination. In the examination, cardiac echo expressed Type II VSD, left
to right shunt and good LVEF (71%); cardiac catheterization, VSD (subaortic type, Qp/Qs: 1.1)
with secondary PS (PG: 30 mmHg); the 64-slice spiral CT, double-chambered right ventricle and
small VSD. Operation correction was indicated. After surgical risk and procedure well explained,
she was admitted for operation and additional administration.
Impression:
Ventricular septal defect
Plans:
1. Therapeutic plan:
VSD repair operation will be performed.
Post-op ICU care
2. Educational plan:
1. Possible of the complication of the operation, including sternal wound infection, low
cardiac output, bleeding.
2. Post-op rehabilitation.
Case 4: Arteriovenous fistula
Chief complain
Poor shunt flow was noted for three days
Present illness
This 55-year-old female of ESRD on regular hemodialysis from right forearm AVF qw (W1, W3, or
W5) at our hospital had: Type 2 DM and hypertension customarily controlled; right forearm A-V
shunt dysfunction and weak thrill for three days. She has been to Yuan’s general hospital where
percutaneous transluminal angiplasty attested about 2 cm long stenosis near the arteriovenous
anastomosis. Poor vein quality was also impressed; to recreate AV fistula was suggested. So she was
transferred to our CVS OPD. After surgical risk and procedure well explained, she was admitted for
further administration.
Impression
Right forearm AV fistula dysfunction
Plan
1. Therapeutic plan:
Recreation of AV fistula over right hand will be performed
2. Educational plan:
1. Possible of the complication of the operation, including bleeding, wound infection, AV
fistula steal syndrome.
2. Making sure the access is checked before each treatment.
3. Not allowing blood pressure to be taken on the access arm.
4. Checking the pulse in the access every day.
5. Keeping the access clean at all times.
6. Using the access site only for dialysis.
7. Being careful not to bump or cut the access.
8. Not wearing tight jewelry or clothing near or over the access site.
9. Not lifting heavy objects or putting pressure on the access arm.
10. Sleeping with the access arm free, not under the head or body
Case 5: Mitral regurgitation
Chief complain
Short of breath for two months
Present illness
This 65 y/o male with dyspnea which first appeared about two months ago when he walked for 5
minutes was relieved after one minute rest. Over the months the symptom progressed and
associated with palpitation (heart rate 120/min), and short ness of breath (respiration rate about
25/min). So he came to our CV OPD where physical examination evinced jugular engorgement and
grade II mid-systolic murmur over the apical region. Additionally, the EKG avowed AF; the
cardiac echo, severe MR, mild pulmonary hypertension, and EF 45%. Surgical intervention was
suggested, so he was transferred to our CVS department.
Impression
Severe mitral regurgitation
1. Diagnostic plan:
Arrange cardiac catheterization, carotid echography
2. Therapeutic plan:
Mitral valve replacement will be performed.
3. Educational plan:
1. Possible of the complication of the operation, including bleeding, wound infection,
respiratory failure, low cardiac output.
2. Post-op rehabilitation
Case 6: Aortic dissection
Chief complain
Chest pain for two hours
Present illness
According to the 65-year-old female and previous chart, she had hypertension for 10 years, but took
no medicine until a stroke with left hemiparesis two years ago. Her current drugs for hypertension
included norvasc 5 mg po; her blood pressure was around 135/90 mmHg. Type II DM was
diagnosed 3 years ago. Her fasting blood glucose was controlled around 140 mg/dl for one year;
HbA1c, at 7% with metformin 500 mg tid.
She suffered frequent chest pain since two hours ago; the sharp pain radiated to the upper back. So
she came to our ER where physical examination envisioned high blood pressure, sharp pain
radiating to the back, cold sweating, jugular vein engorgement, and no syncope.
Moreover, the
chest X-ray manifested mediastinum; the chest CT, Type A aortic dissection and no pericardial
effusion. The operation was suggested. After well explained surgical risks and procedures, she was
admitted for operation and additional administration.
Impression
Type A aortic dissection
Hypertension
1. Therapeutic plan:
Emergency ascending aorta replacement will be performed.
2. Educational plan:
1. Possible of the complication of the operation, including bleeding, wound infection,
respiratory failure, low cardiac output, lower limbs ischemia, renal failure.
2. Post-op rehabilitation
Case 7: Coronary artery disease
Chief complain
Chest pain since today six PM
Present illness
The 60-year-old man with sub-sternal chest pain since six PM today first noted the chest pain 2
months prior to admission, while he washed his car. The above pain would relieve after rest and
recur when he exercised again. Over the next month, the pain became more frequent, often at rest.
One week prior to admission, he discovered the daily pain which was worst on admission after he
was watching TV and which was characteristically sharp, sub-sternal pain, radiating to the back
every 20 to 30 minutes, and lasting 10 minutes per episode. He noted: associated nausea and
diaphoresis; exercising-worsened and lying flat-relieved pain. He smoked one pack a day (30
packs/year antecedently), and had diabetes mellitus for 10 years. Hence, he took OHA (Euglucon 1#
bid) periodically. His fasting sugar was 130-150 mg/dl. For the hypertension for 15 years, he
took norvasc 1# bid habitually; his systolic blood pressure was 120-140 mmHg. For
hyperlipidemia for 10 years, he took lipitor 1# qd regularly; his serum lipid profile projected TG
180 mg/dl, and chol 254 mg/dl. His father aged 82 died of acute myocardial infarction. The case of
no chest pain-connected cough or fever described no sick contacts and had: no chest trauma; no
worsened or improved pain if the chest wall was pressed; heartburn precedingly and no lying flator finishing eating- worsened pain. For suspected coronary artery disease, he was admitted for
further treatment.
1. Diagnostic plan:
Arrange cardiac catheterization, cardiac echography, carotid echography
4. Therapeutic plan:
PTCA, CABG will be performed if indicated..
5. Educational plan:
3. Possible of the complication of the operation, including bleeding, wound infection,
respiratory failure, low cardiac output.
4. Post-op rehabilitation
Case 8: Superficial sternal wound infection
Chief compliant
Sternal wound pus discharge formation for 2 days
Present illness
This 67 year-old male had history of: 1) acute non-ST elevation myocardial infarction (Killip III) in
July 2010; 2) Type 2 diabetes mellitus insulin control for more than 30 years; 3) three-vessel
coronary artery disease and class II stable angina s/p coronary artery bypass graft on September 27,
2010. Post-op, he was re-admitted on October 12, 2010 attributed to pneumonia, heart failure and
DM poor control. Under the medication, his general condition improved, so he was discharged on
October 29, 2010. This time, he suffered sternal wound infection and pus accumulation over
mid-sternotomy wound; hence, he visited Dr. Zheng-handled CVS OPD. The stated poor
control-caused sternal wound infection and poor healing were suspected, so he was referred to ER
and admitted for further administration.
Impression
1. Superficial sternum wound infection
2. Post-CABG
3. DM with poor control
1. Diagnostic plan:
Wound culture collection
2. Therapeutic plan:
1. Wound care with VAC
2. Antibiotic treatment.
3. Educational plan:
1. Possible of the osteomyelitis, bleeding.
2. Blood sugar control, diet control.
Case 9: Abdominal aortic aneusrym
Chief complain
Severe abdominal pain for one day
Present illness
This 79-year-old male with severe abdominal pain for one day was taken to Kao’s general hospital
where the abdominal CT revealed the ruptured abdominal aortic aneurysm (AAA) with
hypovolemic shock. Owing to no CVS Doctor there, he was referred to our ER which observed
unstable hemodynamia with distended abdomen on physical examination. For the said AAA with
hypovolemic shock, he was admitted for surgical intervention.
Impression
Ruptured abdominal aortic aneurysm with hypovolemic shock
1. Therapeutic plan:
1. TEVAR
2. Post-op ICU care
2. Educational plan:
Possible of the rebleeding, wound infection, ileus.
Case 10: Deep vein thrombosis
Chief Complain
Pain and swelling over left calf for one weeks
Present illness
This 40 years old man who denied DM or hypertension history suffered the left calf swelling and
tenderness for 3 days and went to the local orthopedicist who identified left leg cellulitis with
impending compartment syndrome. However, the leg swelling progressed to the lower thigh today.
He was sent to our ER which envisioned: the left leg swelling and tenderness; no erythematous
change. Additionally, the extremities sonography showed thrombosis within the left femoral vein
and popliteal vein. Deep vein thrombosis was diagnosed, so he was admitted for further treatment.
Impression
Deep vein thrombosis
Plan
1. Evaluate of left lower leg
2. Coumadin prescribed
3. Left leg protected with elastic bandage