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Queen of the Valley

1000 Trancas Street


Napa, CA 94558

History & Physical Report

DATE OF ADMISSION: 04/27/2017

DATE OF PROCEDURE: 04/27/2017

PRIMARY OPERATOR: Richard H. Hongo, MD

REFERRING CARDIOLOGIST: Sergio M. Manubens, MD

PROCEDURE TO BE PERFORMED: Catheter ablation for the treatment of atrial


fibrillation.

PREPROCEDURAL DIAGNOSES:
1. Persistent atrial fibrillation.
2. Typical right atrial flutter.

INDICATION FOR PROCEDURE: The patient is an 80-year-old woman first diagnosed


with atrial fibrillation in 2013. She has been treated with metoprolol, with
doses up to 100 mg twice a day, but with continued debilitating palpitations. She
underwent cardioversion with ibutilide on 07/2015, but persistent atrial
fibrillation has recurred. She did not tolerate Multaq because of extreme
malaise. She has been treated with Xarelto 20 mg daily without interruption.

PAST MEDICAL HISTORY:


1. Atrial fibrillation, now persistent.
2. Hypertension.
3. Moderate tricuspid regurgitation.
4. Gastroesophageal reflux disease.
5. Osteoarthritis.

MEDICATIONS:
1. Metoprolol 100 mg twice a day, held for the procedure.
2. Xarelto 20 mg 1 p.o. daily.
3. Protonix 40 mg 1 p.o. daily.

ALLERGIES:
1. AMOXICILLIN.
2. DEMEROL.

SOCIAL HISTORY: No smoking. Does drink alcohol.

REVIEW OF SYSTEMS: The 12-point review of system is negative except she does
bruise easily, her skin is sensitive to sun. She does get heartburn and she
does get uncomfortable with blood draws.

PHYSICAL EXAMINATION:
GENERAL: An 80-year-old woman who is well developed, well nourished, alert and
oriented x3, with normal mood and affect.
VITAL SIGNS: Blood pressure is 140/80 with a pulse rate of 90 beats per
minute. Height 5 feet 5 inches, weight 158 pounds.
HEENT: Normocephalic, atraumatic.
NECK: No jugular venous distention.
HEART: Regular rate, irregular rhythm, 2/6 holosystolic murmur.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, nontender, nondistended.
EXTREMITIES: No clubbing, cyanosis, or edema.

LABORATORY VALUES: Pending.

DIAGNOSTIC DATA: EKG from 02/06/2017 shows atrial fibrillation with a ventricular response of
76
beats per minute, QRS complex of 90 msec, QT interval 387 msec.

EKG from 04/26/2016 shows atrial fibrillation with a ventricular response of 60 beats
per minute.

EKG from 07/17/2015 shows typical right atrial flutter, ventricular response rate of 96 beats per
minute.

ZIO patch ECG monitor done on 07/29/2015 shows 7 days of atrial fibrillation,
100%.

Myo-perfusion scan from 09/03/2013 shows no ischemia.

Echocardiogram from 08/28/2013 shows normal left ventricular ejection fraction.

IMPRESSION: Highly symptomatic persistent atrial fibrillation, drug


refractory. She presents for catheter ablation for the treatment of atrial
fibrillation. She has a history of typical right atrial flutter as well and
this will have to be addressed as well. She has been maintained on Xarelto 20
mg 1 p.o. daily without any bleeding complications.

We went over the procedure again in detail, including risks, benefits, and
Alternatives, and she is wanting to proceed.

PLAN:
1. We will proceed with catheter ablation for the treatment of persistent
atrial fibrillation as well as typical right atrial flutter.
2. We will address whether or not metoprolol is to be restarted after the
procedure. Based on her sinus rate as well as the degree of atrial
fibrillation, ablation then was needed.
3. Continue uninterrupted Xarelto 20 mg 1 p.o. daily.