A 73-Year-Old Female With Palpitations

Background Atrial fibrillation is a commonly encountered clinical problem. Although a large percentage of patients have no dearly identifiable precipitant, secondary atrial fibrillation is a well-documented clinical entity.\u27 Case presentation A 73-year-old female with a history of obstructive sleep apnea, hypertension, and chronic obstructive pulmonary disease presents with complaints of intermittent palpitations, substernal squeezing chest pressure, and shortness ofbreath for two weeks. Her most recent episode occurred on the bus, prompting her to come to the emergency room for evaluation. Further questioning revealed mild weight loss and diarrhea over the prior few weeks. Home medications included amlodipine, baby aspirin, albuterol as needed, and ciprofloxacin for a recently diagnosed URI

Discharge Summaries: How Long Is Too Long?

The Graduate Medical Education (GME) committee is composed of all Jefferson residency and fellowship program directors, as well as ten selected housestaff members. The committee meets monthly to discuss a wide array of topics, including Accreditation Council for Graduate Medical Education compliance, duty hours violations, and program reviews. One recently covered topic was the timeliness of discharge summary dictations. Implementing changes to improve transitions of care remains a focus of all healthcare systems. Jefferson is attempting to take an innovative approach to this issue, and discharge summaries are only one of the areas being examined. The current policy requires house staff to dictate the discharge summary within 14 days of discharge. Delinquent summaries receive a monetary fine on a weekly basis. Attending physicians have up to 120 days from discharge to finalize the summary, which is currently not in line with the Joint Commission mandate of finalized summaries within 30 days of hospital discharge. With increasing emphasis on early outpatient follow-up, many primary care physicians are seeing patients prior to having access to the discharge summary. Because of the disparity between the current policy and goal of timely clinical follow-up, Jefferson is examining the current timeline to address this issue

Anomalous Left Main Coronary Artery Originating from the Right Sinus of Valsalva

Introduction An anomalous left main coronary artery is a rarely seen clinical entity, particularly when it arises from the right sinus of Valsalva. This case report highlights this uncommon finding and how it affects the care of a patient with significant coronary artery disease. Case Presentation A 66 year-old male with a history of hypertension, hyperlipidemia, and type II diabetes presented with progressive exertional mid-epigastric and mid-chest discomfort. The patient stated that he had been feeling this “heaviness” with various activities and occasionally at rest for the past nine months. When it occurred with activity, the pain was generally relieved by rest within several minutes. His medications on presentation included insulin glargine, glyburide, metformin, simvastatin, pioglitazone, and lisinopril. Vital signs at the time of presentation included a temperature of 98.2°F, heart rate of 82 beats per minute, and blood pressure of 130/70 mmHg in both arms. Laboratory investigation showed a total cholesterol of 178 mg/dL (normal range = 150-250), high-density lipoprotein (HDL) cholesterol of 42 mg/dL, low-density lipoprotein (LDL) cholesterol of 111 mg/dL, triglycerides of 123 mg/dL, and hemoglobin A1C of 7.9% (normal range = \u3c5.7%). Pharmacologic nuclear stress testing revealed a severe, medium sized defect in the inferolateral wall that was predominately reversible. Thus, the patient underwent a cardiac catheterization which revealed an anomalous left main (LM) coronary artery arising from the right sinus of Valsalva separately from the origin of the right coronary artery (RCA). The distal left anterior descending artery (LAD) had a total occlusion, while the RCA had several areas of 70% stenosis. A subsequent coronary CT scan displayed an anomalous left coronary artery coursing anterior to the pulmonary artery (Figures 1, 2). The CT scan also showed moderate to high grade RCA stenosis in the mid to distal area of the vessel, as well as high-grade stenoses in the small-sized LAD and left circumflex arteries

Underutilization of Statins and Aspirin Following Coronary Artery Bypass Graft Surgery

Introduction Coronary artery bypass graft (CABG) surgery continues to be an important procedure for the treatment of coronary artery disease. However, clinically significant stenoses and complete bypass graft occlusion rates remain high, especially among saphenous vein grafts1. This is associated with significant morbidity and mortality. Both statin medications and aspirin have been shown in numerous clinical trials to play an important role in the medical management of coronary artery disease following CABG surgery. As per the ACC/AHA guidelines, both statin medications and aspirin have class I indications to support their use indefinitely following CABG, unless contraindication exists2. Long term studies evaluating statin and aspirin usage rates following CABG procedures are lacking. Purpose The goal of this study was to assess the usage rates of statins and aspirin in post-CABG patients undergoing coronary angiograms. Further analysis was done to assess the clinical and laboratory differences among the populations based on medication usage group