MEDICAL SUMMARY “post cardiac arrest” as written by Cardiologist, Essentia Health Care System
Mr. Shane Johnson is a 41-year-old gentleman from Embarrass, Minnesota, who has a history of atherosclerotic coronary artery disease. His situation begins about four weeks ago when while in Afghanistan working for a private contractor he had begun to experience increasing fatigue and shortness of breath. This then escalated to the point where he then began having some mid sternal chest heaviness. He sought help from the medic that was assigned to their work force. That medic appropriately thought the ·patient was most likely having a heart attack and accordingly made arrangements for the patient to be transferred to a field hospital. About 2-1/2 hours later the patient did arrive at a Slovenian field hospital which was basically a tent facility. They had minimal resources there but did treat the patient with Morphine and Fentanyl therapy and I believe possibly nitrates. It took them about 2-1/2 days to be able to make arrangements for the patient to be transported to a medical center. This was done by private airplane and the patient eventually landed in Dubai close to three days following his myocardial infarction. In Dubai he underwent angiography and had stents placed in his circumflex artery. He then was hospitalized in Dubai for about two or three days until he could subsequently be transferred ·back to the United States with medical attendance. He was here in the United States and visiting with his lawyer on the day after he had arrived back. They had been out to lunch and then returned to the lawyer’s office and while in the lawyer’s office, he suffered a cardiac arrest. His lawyer administered CPR and the patient was transferred to the emergency room in Virginia, and subsequently here to St. Mary’s Medical Center. Upon arrival here as noted above, he underwent coronary angiography. His coronary artery status was felt to be stable at this time. It was then felt in that he had a history of myocardial infarction and widely patent coronary arteries and had suffered an out of hospital cardiac arrest that he met primary indications for AICD implantation prior to discharge from the hospital. Our plans had been for implantation on the Monday morning; however, when the patient was assessed he was noted to have cellulitis of the right arm. This cellulitis appeared to be related to a intravenous site in the right antecubital space. We believe this intravenous site was either one from his experiences in the Middle East or possibly the out of hospital start at the time of his cardiac arrest. In any case this cellulitis became quite extensive and traveled all the way up the arm to the shoulder level and down the arm to the mid forearm. He was seen in infectious disease consultation. All plans for implanting a device were put on hold related to this. Blood cultures were performed and these were positive for staphylococcal aureus. Fortunately this was not a Methicillin-resistant strain. Accordingly, he was treated with Clindamycin therapy. We delayed AICD implantation for approximately a one week course of antibiotic therapy. Eventually his cellulitis did improve and at the time of implantation he did not have any erythema of the right arm. Unfortunately, as the cellulitis improved and we were better able to assess that right arm, it was noted that from the antecubital space on up to the axilla area, the vein was quite firm and somewhat painful to the patient. Accordingly we obtained the above-noted ultrasound and there was evidence of thrombophlebitis. Accordingly, he was placed on Heparin therapy. Heparin therapy was discontinued prior to AICD implantation and in discussion with Drs. Mollerus and Ginete, it was felt that he was at higher risk for bleeding post AICD implantation than he was for clot embolization and accordingly Heparin was not restarted. The patient was; however, initiated on Coumadin therapy the night of his implantation and we will plan for a six week course of Warfarin therapy. Post implantation, the patient has had some significant issues with discomfort related to the deep submuscular implant. He has been receiving intravenous pain medications. He feels that his pain level is getting under control and he is being transitioned to oral therapy and will hopefully be able to be discharged to home tomorrow, 11/22/2008. Recent labs include a WBC of 12,900, hemoglobin 14.1, platelet count 468,000 . . On the day prior to discharge, the patient’s INR is 1.3. A recent renal profile revealed sodium of 135, potassium 4.0, BUN 8, creatinine 0.7. Blood cultures are now showing no growth after his course of antibiotic therapy.
MD PRINCIPAL DIAGNOSIS:
Atherosclerotic coronary artery disease with cardiomyopathy status post out of hospital cardiac arrest with subsequent AICD implantation complicated by right arm cellulitis, thrombophlebitis with septicemia.
- Atherosclerotic coronary artery disease status post-acute myocardial infarction with subsequent PTCA and stent placement to the circumflex artery in Dubai approximately four weeks ago.
- History of nicotine addiction.
- Gastroesophageal reflux disease.
- Sleep apnea with plans for sleep study within the next month.
- Decreased left ventricular function with ejection· fraction of 38%
11/07/2008: Coronary angiography (Dr. Mark Neustel). Ejection fraction 40% with apical hypo kinesis. Please see procedure report for complete details.
11/10/2008: Echocardiogram (Dr. Nizar Saleh). Mildly enlarged left ventricle with mild to moderately reduced left ventricular systolic function with ejection fraction estimated to be approximately 40%. Trace MR and mild TR. Please see procedure report for complete details.
11/14/2008: Ultrasound of the right upper extremity veins revealing that the cephalic vein was thrombosed with mixed echogenicity clot from the forearm to the shoulder. The brachial and basilic veins are patent. Normal flow patterns and venous wave forms. Impression was thrombosis of the cephalic vein.
11/19/2008: Dual chamber AICD implantation (Dr. Michael Mollerus). Indication: Out of hospital cardiac arrest with history of myocardial infarction and decreased left ventricular function. The device is a Medtronic Secure DR, model #D224DRG, serial #PUG200663H. The atrial lead is a Medtronic 5076-52 em, serial #PJN1686997. The right ventricular lead is a Medtronic Sprint Quatro Secure, serial #TDG272796V, 6947-65 em. On the morning following implantation, device interrogation revealed a P-wave amplitude of 3.3 millivolts with atrial capture 0.75 volts at 0.5 milliseconds with atrial impedance 794 ohms. The R-wave amplitude was 17.6 millivolts with RV capture 0.5 volts at 0.5 milliseconds with impedance 627 ohms. HVAHVV impedance 37, 47 on the SVC coil. VT zone is at 167 with VF zone at 200. The patient was A paced and D paced at less than 1%. His intrinsic rhythm was sinus at 60 beats per minute with a first degree AV block of 0.24. Pacing mode is programmed to AAIR/DDDR at 50-130. On the morning following implantation, chest x-ray reveals leads in good placement with no evidence of hemo or pneumothorax. . The left upper chest wall implantation site is clean, dry and intact with Steri-Strips and a dry sterile dressing in place. There is no evidence of hematoma. This is a sub muscular implant.
|Cardiac arrest – ventricular fibrillation||11/21/2008|
|Coronary atherosclerosis of native coronary artery||11/21/2008|
|MI (myocardial infarction)||11/21/2008|
|Chronic systolic heart failure (HCC)||11/21/2008|
|Cellulitis of arm||11/21/2008|
|Long term (current) use of anticoagulants||11/24/2008|
|GERD (gastroesophageal reflux disease)||11/05/2009|
|Cellulitis and abscess of leg||01/05/2010|
|Sprain and strain of medial collateral ligament of knee||01/05/2010|
|Automatic implantable cardiac defibrillator||10/01/2012|
|Unstable angina (HCC)||02/01/2013|
|percutaneous transluminal coronary angioplasty||02/05/2013|