Wiliam Sepulvado
John XXXX – AndroGel/Testosterone Case Review
|Parameter |Findings |PDF Ref |
|First name |John |14 |
|Initial |D |17 |
|Last name |XXXX |14 |
|DOB |07/03/YYYY |14 |
|Gender |Male |56 |
|Past Medical History and Risk Factors |History Of Cardiac Problems: Longstanding hypertension |56 |
| |Stroke: No | |
| |Valve prolapse: No | |
| |Coronary Artery Disease: No | |
|Social History (Smoking, alcohol, drug|Has he ever been a tobacco user? Yes |86 |
|use, etc.) | | |
| |Period of time smoking: Unknown | |
| |Heaviness of smoking: 20 pack year exposure | |
| |Has she quit smoking? Yes | |
| |When did she quit: 20 years ago | |
|Family History |DM: (List all family members diagnosed with DM): No | |
| |Heart Disease: No | |
|Drug Interactions If Any |None |86 |
|Age at the time of Testosterone use (>|67 years (> 65 years) |148, 151-153 |
|or < 65 years) | | |
|Weight, Height, BMI Details of the |Per visit dated 02/14/YYYY; |20 |
|patient (At the time of Testosterone |Height: 5 feet, 9 inches | |
|use) |Weight: 81 kg | |
| |Body Mass Index (BMI): 25 kg/m2 | |
|AndroGel/Testosterone Use Details |Reason for Use: Andropause |9, 148, 151-153, |
| | |171-174 |
| |Topical/Supplemental therapy: Topical | |
| | | |
| |Start Date: 08/28/YYYY | |
| | | |
| |Duration: 08/28/YYYY, 08/29/YYYY, 10/10/YYYY, 10/24/YYYY (Per medical records) | |
| | | |
| |Stop Date: Unknown | |
| | | |
| |Dosage: AndroGel 5 gm | |
| | | |
| |*Reviewer's comment: Pharmacy records are not available to know the AndroGel usage details. | |
|Testosterone lab values (One month |09/04/YYYY: Testosterone – 6.6 nmol/L (Ref. range: 6.0-27.0 nmol/L) |33 |
|prior and after adverse event) | | |
| |*Reviewer's comment: Testosterone lab value one month after adverse event is not available for review. | |
|Diagnosed with Adverse Events (Heart |Yes |56-61 |
|attack/Stroke/DVT/Blood clots/other | | |
|Cardiovascular events) |Date of diagnosis: 10/10/YYYY | |
| | | |
| |Adverse Event Diagnosis: ST-segment Elevation Myocardial Infarction (STEMI) with identified triple vessel | |
| |Coronary Artery Disease (CAD) and Ventricular Septal Defect (VSD) | |
| | | |
| |Did the adverse event occur within 30 days of Testosterone therapy? Yes | |
|Whether Testosterone was discontinued?|No |171-174 |
|(When and Why) | | |
| |*Reviewer's comment: The discharge medications for hospitalization for myocardial infarction contain | |
| |AndroGel 5 gm. | |
|Hospitalization for the adverse event |1st Hospitalization – For STEMI with identified triple vessel CAD and VSD: 10/10/YYYY-10/24/YYYY (15 days)|56-61, 86-87, |
|(Admission, length of hospital stay) | |88-92, 100-101, |
| |2nd Hospitalization - For Congestive Heart Failure (CHF): 10/25/YYYY-10/28/YYYY (4 days) |96-97, 102-103, |
| | |185-187 |
| |3rd Hospitalization – For refractory CHF: 11/12/YYYY-11/20/YYYY (9 days) | |
| | | |
| |4th Hospitalization – For acute decompensated heart failure: 11/20/YYYY-12/02/YYYY (13 days) | |
| | | |
| |5th Hospitalization – For patch dehiscence and VSD: 12/02/YYYY-12/08/YYYY (7 days) | |
|Complications after Adverse Event |10/25/YYYY-10/28/YYYY: CHF |86-87, 88-92, |
|Diagnosis |11/12/YYYY-11/20/YYYY: Refractory CHF |100-101, 96-97, |
| |11/20/YYYY-12/02/YYYY: Acute decompensated heart failure |102-103, 185-187 |
| |12/02/YYYY-12/08/YYYY: Patch dehiscence and VSD | |
|Current Condition of Patient (as per |06/05/YYYY: Patient denies chest pain, SOB and Paroxysmal Nocturnal Dyspnea (PND). Prescribed |11 |
|last available record) |Nitro-Glycerin for CAD/CHF. | |
|Prior Medical History |Past Medical History: Longstanding hypertension, gout |56, 86, 151 |
| | | |
| |Past Surgical History: Umbilical hernia repair, colonoscopy | |
| | | |
| |Social History: As on 10/28/YYYY: Former smoker – 20 pack year exposure, quit 20 years ago; Excess alcohol| |
| |consumption, drinking as much as 10-12 drinks in the past per day, but has been abstinent of alcohol for | |
| |the last year | |
| | | |
| |Family History: Non-contributory | |
| | | |
| |Allergy: Beer only insofar | |
AndroGel/Testosterone Intake Details (From Pharmacy Bills) Not available
*Reviewer's comment: Pharmacy records are not available to know the AndroGel usage details.
|Duration |Medication |Prescribed By |Dispensing Pharmacy |PDF Ref |
Missing Medical Record:
|What Records are Needed |Hospital/ |Date/Time Period |Why we need the records? |Is Record Missing |Hint/Clue that records |
| |Medical Provider | | |Confirmatory or Probable? |are missing |
Detailed Chronology
|DATE |PROVIDER |OCCURRENCE/TREATMENT |PDF REF |
|01/06/YYYY-09/04/Y|Multiple Providers |Multiple visits for umbilical hernia: |22-23, 25-28, |
|YYY | | |3-6, 180-181, |
| | |08/28/YYYY: Patient is diagnosed to have andropause. Prescribed AndroGel pump 5 gm, scheduled 30 days. (PDF Ref: 9) |7-9, 14, 33 |
| | | | |
| | |09/04/YYYY - Labs: (PDF Ref: 33) | |
| | |Testosterone – 6.6 nmol/L (Ref. range: 6.0-27.0 nmol/L) | |
|10/10/YYYY-10/24/Y|Provider/Hospital |Hospitalization for acute ventricular septal defect complicating inferior ST elevation Myocardial Infarction (MI): |56-57, 35-36, |
|YYY | | |62-63, 66-75, |
| | |Admission diagnosis: ST-segment Elevation Myocardial Infarction (STEMI) with identified triple vessel coronary artery |108-115, 83, |
| | |disease and Ventricular Septal Defect (VSD) |182, 58-61 |
| | | | |
| | |Secondary diagnoses: | |
| | |ST elevation MI 10/10/YYYY (Late presentation), cardiogenic shock. | |
| | |Gout - Takes Allopurinol for maintenance | |
| | |Hypertension | |
| | |Remote smoker | |
| | | | |
| | |Interventions and major investigative procedures: | |
| | |10/10/YYYY: Coronary Artery Bypass Grafting (CABG) times 3; Left Internal Mammary Artery (LIMA) to Left Anterior | |
| | |Descending (LAD), Saphenous Vein Graft (SVG) to diagonal one and Obtuse Marginal (OM) and infarct to VSD with VSD | |
| | |repair with pericardial patch. | |
| | |10/20/YYYY: Left elbow X-ray shows no acute fracture or dislocation post fall. | |
| | |10/21/YYYY: Postoperative chest X-ray reveals bibasilar atelectasis with small bilateral pleural effusions. | |
| | |10/22/YYYY: Postoperative echocardiogram to assess VSD shows a 1.0 cm residual VSD and residual tissue around the VSD | |
| | |site. | |
| | | | |
| | |During his hospital stay this patient was transfused with 4 units of frozen plasma, 1 unit of pooled platelets and 1 | |
| | |unit of Packed Red Blood Cells (PRBCs). | |
| | | | |
| | |Course in hospital: Patient presented on 10/10/YYYY with a late presentation inferior ST elevation MI and heart | |
| | |failure. Investigations revealed triple vessel Coronary Artery Disease (CAD) and a VSD. The patient was taken to the | |
| | |Operating Room (OR) on 10/10/YYYY. He underwent CABG and VSD repair with Dr. Xxxx. The procedure was well tolerated. | |
| | |This patient had a prolonged stay in Cardiovascular Intensive Care Unit (CV ICU). He remained there until | |
| | |postoperative day #6. | |
| | |His issues there included: | |
| | |Intraaortic balloon pump which was inserted preoperatively was removed on postoperative day #1. | |
| | |Patient was intubated until postoperative day #2. | |
| | |Patient was received to CV ICU on Milrinone, Levophed and Vasopressin. All were discontinued by postoperative day #3. | |
| | |Patient was fluid volume overloaded requiring treatment with BiPAP and diuresing. | |
| | |This patient was in a junctional rhythm from postoperative day zero to postoperative day #2. He then reverted to a | |
| | |sinus rhythm and remained in sinus rhythm throughout the course of his stay. | |
| | | | |
| | |The patient was transferred to the Cardiac Surgery ward on postoperative day #6. The patient had some confusion on | |
| | |postoperative day #7. It was identified that he had not been sleeping well. He was treated with Seroquel. This | |
| | |improved his sleep wake pattern and resolved his hallucinations and confusion. This was continued for a duration of | |
| | |three days. | |
| | | | |
| | |This patient remained in sinus rhythm throughout his postoperative course. He remained on telemetry until | |
| | |postoperative day #8. | |
| | | | |
| | |This patient was found to have a systolic ejection murmur on postoperative day #11. Echocardiogram was repeated and | |
| | |showed a small residual VSD of 1.0 cm. As the patient was asymptomatic it was not felt that any intervention was | |
| | |required at this time. The patient was advised to monitor for signs of heart failure. He was advised to weigh himself | |
| | |daily, monitor for peripheral edema and shortness of breath. The patient has no dizziness at the time of discharge and| |
| | |again did not have any arrhythmias while in hospital. I have requested this patient see Dr. Xxxx in approximately one | |
| | |week with a repeat echo. | |
| | | | |
| | |The patient’s only other postoperative issue was that of gout. He had an acute gout attack of the left forefoot. He | |
| | |was treated with Colchicine and had quick resolution of his symptoms. This patient is anticoagulated for six months | |
| | |for a VSD patch. Target INR is 2.0 to 3.0. INR at the time of discharge is 3.1. | |
| | | | |
| | |Patient is being discharged home to the support of his family on postoperative day #14, 10/24/YYYY. | |
| | | | |
| | |Most responsible diagnosis: Triple vessel coronary artery disease and VSD. | |
|10/25/YYYY-10/28/Y|Provider/Hospital |Hospitalization for congestive heart failure: |37-39, 84, |
|YYY | | |86-87 |
| | |History reviewed. Patient was discharged last Thursday after he had an inferior MI and within a few hours was | |
| | |readmitted through the Emergency Department (ED) at XYZ Memorial Hospital with Congestive Heart Failure (CHF), has | |
| | |diuresed over the last three days with good response. (ED reports are not available). He says he is feeling back to | |
| | |normal. He has had no arrhythmias documented, no chest pains. His troponin has declined from his previous infarct. No | |
| | |secondary bump. His ECG has shown evidence for his inferior MI but no acute changes. | |
| | | | |
| | |On examination, blood pressure is 100/60, heart rate is 65. He is in a sinus rhythm. Chest examination reveals | |
| | |diminished air entry to both bases but I did not hear any crackles or wheezes. Heart sounds reveal a harsh systolic | |
| | |murmur at the left sternal border, heard throughout the precordium, also into the back. There are no diastolic murmurs| |
| | |heard. Jugular Venous Pulse (JVP) is at the sternal angle with a negative Hepatojugular Reflux (HJR). The sternal and | |
| | |leg wound sites appear to be healing. | |
| | | | |
| | |10/28/YYYY – Discharge summary: Patient’s Echocardiogram (ECG) shows grade II-III Left Ventricular (LV), Ejection | |
| | |Fraction (EF) 40% with inferior wall severe hypokinesis, mild global hypokinesis, about a 1 cm residual VSD with a QP | |
| | |QS of 1.7. No pericardial effusion but left pleural effusion is still noted. Pulmonary pressures are mildly elevated. | |
| | |Right Ventricular Systolic Pressure (RVSP) is in the mid 40-45 range. His ECG shows evolving changes of his inferior | |
| | |MI but no acute changes. There were no arrhythmias documented. His renal function has tolerated the bump up of the | |
| | |diuresis. | |
| | | | |
| | |His chest X-ray is showing some resolution of his congestive heart failure. His blood work did show him to be anemic, | |
| | |hemoglobin was 10.3. He is therapeutic with an INR of 2.4 on adjusted dose Warfarin, having received 1 mg of Warfarin | |
| | |today. He has diuresed well and is doing well. The congestive heart failure could be representative of his recent MI, | |
| | |LV impairment, residual VSD and volume overload there-from. This does not represent a secondary acute ischemic event. | |
| | |He is eager for discharge home and as he is clinically stable, discharged to home today. He has been put on Nitro-Dur | |
| | |0.4 mcg patch. He has been reminded to carry Nitro and to seek medical attention for any refractory symptoms. | |
| | |Subsequent followup has been organized and cardiac rehabilitation through my office. | |
|11/01/YYYY |Provider/Hospital |Follow-up visit status post MI, CABG and VSD: |10 |
| | | | |
| | |Patient complains of shortness of breath and chest pain. | |
| | | | |
| | |Assessment and plan: MI and VSD – Follow-up in 2 weeks. | |
|11/12/YYYY-11/20/Y|Provider/Hospital |Hospitalization for refractory CHF: |88-92, 44-45, |
|YYY | | |100-101 |
| | |Course in hospital: Patient presented to Emergency Room (ER) on 11/12/YYYY because of acute onset Shortness of Breath | |
| | |(SOB) associated with cough and generalized weakness. He was put on a strict 1.5 grams salt and 1.5 liters fluid | |
| | |restricted diet and was diuresed with Intravenous (IV) Lasix and addition of Metolazone. Advise was given by Dr. Pppp | |
| | |for this patient’s management and since he did not respond much to the diuretics resulting in creatinine creeping up | |
| | |from 148 to 170, bicarbonate increasing from 27 to 38 and a moderate luck with urine output his case was discussed | |
| | |with Dr. Xxxx who transferred him over to ABC Hospital and reevaluated him for the ventricular septal detect, which | |
| | |was most likely contributing to his refractory heart failure. He did have elevated Liver Function Tests (LFTs) with an| |
| | |alkaline phosphatase of 298, Alanine Transaminase (ALT) of 228, Aspartate Transaminase (AST) of 98. This bump in the | |
| | |liver enzymes is most likely secondary to congestion from his heart failure. | |
| | | | |
| | |A chest X-ray showed unchanged stable bilateral airspace disease and pleural effusions. During this hospitalization, | |
| | |he did complete a 7-day course of Levaquin and had mild elevation in his white count 13.6; however, his symptoms did | |
| | |not support the diagnosis of pneumonia. I would leave it for the Physicians to decide in ABC whether they want to | |
| | |treat him with another round of antibiotics. After discussing with Dr. Xxxx, his Coumadin was discontinued and he was | |
| | |bridged on Tinzaparin for a possible surgical intervention in the near future. He was discharged on Ferrous Gluconate | |
| | |300 mg, Lasix 60 mg and Aspirin 81 mg. | |
| | | | |
| | |Final diagnosis: Refractory CHF secondary to recent MI resulting in VSD | |
|11/20/YYYY-12/02/Y|Provider/Hospital |Hospitalization for acute decompensated heart failure: |96-97, |
|YYY | | |93-95,98-99, |
| | |Admitting diagnosis: Acute decompensated heart failure |102-103 |
| | | | |
| | |Secondary diagnosis: Significant large residual VSD with a left-to-right shunt | |
| | | | |
| | |Interventions and major investigative procedures: Patient had a 2-D echo that revealed grade I to II out of IV Left | |
| | |Ventricular (LV) function, septal bounce. Basal inferior aneurysmal area. Remaining LV had normal function. The LV was| |
| | |dilated. The Right Ventricle (RV) was hypokinetic and dilated. There was a VSD with a left-to-right shunt, evidence of| |
| | |bilateral pleural effusion, query echodense structure near the Left Ventricular Outflow Tract (LVOT). They wondered if| |
| | |this was part of the VSD closure. His RVSP was 44 mmHg. | |
| | | | |
| | |The CT of his chest 11/26/YYYY showed mixed air space disease and ground glass density in both upper lobes which may | |
| | |be due to edema and infection. Bilateral pleural effusions, larger on the left side with left lower lobe atelectasis. | |
| | | | |
| | |He also had a Transesophageal Echocardiogram (TEE) performed on 11/28/YYYY which showed aortic sclerosis, mild Mitral | |
| | |Regurgitation (MR), mild Tricuspid Regurgitation (TR), RVSP was 46 to 50 mm Hg, the VSD patch was visualized just | |
| | |below the AV valve near the LVOT, and there was evidence of a large residual left-to-right shunt. | |
| | | | |
| | |Most responsible diagnosis: Acute decompensated heart failure secondary to a 3 cm hemodynamically significant VSD | |
| | | | |
| | |Post-admit comorbidities: Include refractory heart failure as well as concerns for embolic phenomenon as he did | |
| | |develop black spots in his nail beds of the fingers bilaterally which was felt to be compatible with embolic | |
| | |phenomenon likely from the pericardial patch tissue now in the LV and LVOT as described. He has been on full-dose | |
| | |Enoxaparin during his admission. | |
| | | | |
| | |Summary: Patient remains on a Lasix infusion but has had refractory heart failure. Dr. Xxxx spoke with Dr. Eric Xx at | |
| | |General Hospital for consideration of a percutaneous closure and therefore he was transferred to General Hospital | |
| | |(TGH) today for an opinion regarding this matter. He will be admitted under Dr. Vlad xxxxin the Coronary Care Unit | |
| | |(CCU) at General. Once their assessment is done he will be repatriated back to our hospital for discharge planning. | |
|12/02/YYYY-12/08/Y|Provider/Hospital |Hospitalization for patch dehiscence and VSD: |185-187 |
|YYY | | | |
| | |Patient was transferred to TGH for consideration of percutaneous VSD repair. Unfortunately after careful review of his| |
| | |clinical status, cardiac MRI and CT by the Interventional Radiologists here he was not deemed a candidate for | |
| | |percutaneous procedure. Cardiovascular Surgery was also consulted and it was thought it would be best for the original| |
| | |Surgeon to operate at ABC who was agreeable to this. During his stay at the CCU at General he showed signs of | |
| | |increasing heart failure 3:1 right to left shunt and high wedge pressures. He was treated with Nipride, Milrinone and | |
| | |Lasix infusions. He also developed delirium and confusion during his stay. CT head did not show anything acute to | |
| | |explain his confusion. | |
| | | | |
| | |Follow-up instructions: VSD dehiscence: For repair at ABC where he has been accepted. Patient is being transferred | |
| | |with infusions of Milrinone, Lasix infusion and Nipride via air ambulance. Metolazone was also added for management of| |
| | |his heart failure. | |
|12/09/YYYY-01/01/Y|Provider/Hospital |Hospitalization for VSD: |189-194, 116, |
|YYY | | |200, 121-122, |
| | |Admitting diagnosis: VSD |117-120 |
| | | | |
| | |Interventions and major investigate procedures: | |
| | |12/10/YYYY: Redo VSD repair for dehiscence of old VSD patch, repair of left false aneurysm and repair of right femoral| |
| | |artery. | |
| | |12/10/YYYY: CT head shows a normal exam. | |
| | |12/12/YYYY: Feeding tube insertion. | |
| | |12/20/YYYY: Thoracentesis for 425 mL on the right side. | |
| | |12/20/YYYY: CT chest shows good opposition of sternal fragments with intact sternal wires. | |
| | |12/23/YYYY: Postoperative echo shows a small residual VSD. QT/QS is 0.9. | |
| | |12/30/YYYY: Postoperative chest X-ray reveals moderate atelectasis at the right lung base with a residual moderate | |
| | |pleural effusion which is unchanged since previous thoracentesis. | |
| | | | |
| | |During his hospital stay this patient was transfused with 11 units of packed red blood cells, 4 units of frozen | |
| | |plasma, 1 unit of pooled platelets, 1 unit of platelet apheresis, 10 units of pooled cryoprecipitate. | |
| | | | |
| | |Course in hospital: Patient underwent redo VSD repair, repair of the left ventricle for false aneurysm and repair of | |
| | |the right femoral artery on 12/10/YYYY. The operative course was well tolerated. | |
| | | | |
| | |The patient had a prolonged stay in CV ICU. His stay was prolonged secondary to: | |
| | |Postoperative bleeding requiring transfusions. | |
| | |Prolonged intubation. This patient was not extubated until postoperative day #8. | |
| | |Small bowel feeding tube inserted on postoperative day #2 for nutritional support while still intubated. | |
| | |Postoperative delirium. The patient was agitated and had a very slow neurological progress. | |
| | |Neurologically he was improving by postoperative day #8. | |
| | |Postoperative atrial fibrillation treated with Amiodarone and Metoprolol. | |
| | | | |
| | |The patient was transferred to the Cardiac Surgery ward on postoperative day #9. This patient continued to have a | |
| | |significant delirium. He was seen by the Geriatric Service as well as Psychiatry. The patient’s family had a concern | |
| | |that given his history of bipolar diagnosis that this was something more than a delirium. Neither the Geriatric nor | |
| | |Psychiatry team felt this was anything other than delirium. The patient had no signs of infection. He had good effect | |
| | |with treatment with Seroquel. His hallucinations resolved. His intermittent episodes of confusion also resolved. By | |
| | |the time of his discharge there were no concerns regarding ongoing delirium from the Nursing Staff, the patient or his| |
| | |family. It was recommended the patient remain on Seroquel. This has been continued in the home environment with | |
| | |request for followup with Dr. Ssss for weaning and discontinuing as appropriate. | |
| | | | |
| | |This patient is anticoagulated for his VSD. This should continue for 3 months. He did have some intermittent atrial | |
| | |fibrillation while in hospital. Reassess his rhythm prior to discontinuing Warfarin therapy. He has maintained a | |
| | |therapeutic INR in hospital on 2 mg of Warfarin daily. | |
| | |This patient had hypernatremia on initial transfer to the Cardiac Surgery ward. This resolved and his sodium was 142 | |
| | |at the time of his discharge. | |
| | |This patient did initially have a sternal click. This was not appreciated by the time of his discharge. The patient | |
| | |however did have dehiscence of his distal sternal incision. At the time of his discharge he was receiving Vac therapy.| |
| | |There were no signs of infection and cultures had been negative. He is not on antibiotic therapy at the time of his | |
| | |discharge. Home Care Services have been requested to monitor the incision and complete dressing changes. Vac/negative | |
| | |pressure wound therapy has been requested in the community. | |
| | | | |
| | |This patient did have a significant right pleural effusion in hospital. This was diuresed on postoperative day #10 for| |
| | |425 mL. He was left with a residual moderate sized right pleural effusion. By serial chest X-ray this was not | |
| | |increasing in size. | |
| | | | |
| | |This patient’s postoperative echo did show a small residual VSD. This was reviewed by Dr. XXXXX and Dr. XX. The | |
| | |results were then communicated to Dr. Xxxx. It was felt that this residual VSD was “insignificant.” Dr. Xxxx has | |
| | |identified that no specific followup is required. Specifically no urgent office assessment or echocardiogram is | |
| | |required at this time. It was relayed to the patient and his spouse. They know to continue to monitor for any signs of| |
| | |failure which could be due to LV dysfunction, or VSD. They also note to monitor for any signs of worsening shortness | |
| | |of breath due to his pleural effusion. | |
| | | | |
| | |This patient was discharged home on postoperative day number 22, 01/01/YYYY. He has been referred to the Cardiac | |
| | |Rehabilitation Program at St. Mars’s General Hospital. | |
| | | | |
| | |Recommendations: | |
| | |This patient requires anticoagulation with Warfarin/Coumadin for 3 months for a VSD repair. He also had intermittent | |
| | |atrial fibrillation postoperatively. Target INR is 2.0 to 3.0. INR at the time of discharge is 2.6. He has been | |
| | |instructed to take Warfarin 2 mg orally daily. | |
| | |His postoperative echo shows a small residual VSD. QP/QS is essentially normal. Dr. Xxxx has identified this VSD to be| |
| | |“insignificant.” Patient is aware of symptoms to monitor for and to seek medical attention should these develop. | |
| | |He has a moderate right pleural effusion. This is residual post thoracentesis. The patient is asymptomatic at the time| |
| | |of his discharge. He is aware to monitor for signs of shortness of breath and to contact his Physician for assessment | |
| | |should this develop. | |
| | |He has a sternal incision which has dehisced at the distal portion. I have requested Vac/negative pressure wound | |
| | |therapy in the home setting. Should there be any concerns regarding the heating of this wound, the patient should | |
| | |followup with Dr. Xxxx. | |
| | |He is on Furosemide and Spironolactone for LV dysfunction. | |
| | |He is on Seroquel and should have intermittent ECG assessments for QT prolongation. I would request that the Family | |
| | |Physician provide the patient with a requisition for this as it was not provided | |
|01/02/YYYY |Provider/Hospital |Medication sheets: |132 |
| | | | |
| | |Aspirin – 81 mg | |
| | |Warfarin – 2 mg | |
|01/10/YYYY-06/05/Y|Multiple Providers |Multiple visits status post CABG and VSD repair: |10, 147, 20, |
|YYY | | |11 |
| | |@ 01/10/YYYY: Patient complains of occasional chest pain, but denies SOB. | |
| | | | |
| | |@ 01/14/YYYY: Patient is recovering slowly and as expected. He is required to use a walker. He is unable to bend or | |
| | |stoop and requires assistance in dressing. He is unable to bath on his own and requires the assistance showering. | |
| | | | |
| | |@ 02/13/YYYY: Cardiac Rehabilitation: Patient is on Warfarin, will discontinue Aspirin. Will reassess LV function in 3| |
| | |months. If EF still less than 30%, may be a candidate for Automatic Implanted Cardioverter Defibrillator (AICD). | |
| | | | |
| | |@ 03/18/YYYY: Patient denies chest pain and SOB. | |
| | | | |
| | |@ 06/05/YYYY: Patient denies chest pain, SOB and Paroxysmal Nocturnal Dyspnea (PND). Prescribed Nitro-Glycerin for | |
| | |CAD/CHF. | |
| | | | |
| | |*Reviewer's comment: Further medical records after 06/05/YYYY are not available to know the progress of the patient. | |
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