Discharge Summary Difficulty breathing, hypertension, tachycardia
CHF secondary to mitral valve prolapse
Admitting
Diagnosis:
Final
Diagnosis:
History of
Present
Illness:
Summary
of Hospital
Course:
Patient was brought to the Emergency Room by her family because of difficulty breathing and palpitations
Patient reports that she has experienced these symptoms for the past 6 months, but this episode is more
severe than any previous. Upon admission in the ER, heart rate was 120 beats per minute and blood pressure
was 180/110. The results of an EKG and cardiac enzyme blood tests were normal. She was admitted for a
complete workup for tachycardia and hypertension.
Patient underwent a full battery of diagnostic tests. A prolapsed mitral valve was observed by
echocardiography. A stress test had to be stopped early due to onset of severe difficulty in breathing.
Angiocardiography failed to demonstrate significant CAD. Blood pressure and tachycardia were con-
trolled with medications. At discharge, HR was 88 beats per minute and blood pressure was 165/98.
There was no evidence of a myocardial infarction or significant CAD. Pellent was placed on a low-salt
and low-cholesterol diet. She received instructions on beginning a carefully graded exercise program.
She is to continue her medications. If symptoms are not controlled by these measures, a mitral valve
replacement will be considered.
Discharge
Plans:
Term
Definition