HISTORY PRESENT ILLNESS: This 77-year-oldman was hospitalized at Crescent City Hospital with chest pain,where a diagnosis of myocardial infarction was made. The patienthad CPK elevation to 800 units per liter. The patient wassubsequently discharged home and, within 24 hours, he wasrehospitalized because of heart failure and cardiac arrhythmia. Thepatient was transferred to University of California Hospital in SanFrancisco for further cardiac evaluation. He underwent cardiaccatheterization and coronary angiography. His ejection fraction wasaround 30% to 35%. He has severe left main coronary artery stenosisand right coronary artery occlusion.
The patient had a laparotomy in October200x for bowel obstruction. The patient had a carcinoid tumor
resected 4 or 5 years ago. During recentlaparotomy, he was found to have diffuse carcinoid involvement ofthe liver and mesentery. The patient did have small-bowelresection. He now has a colostomy. The patient is expected to live2 to 3 years.
PAST HISTORY: History of long-standinghypertension. The patient has colostomy for diverticular
bleeding in 200x. He has had transurethralresection of the prostate. He had recent small bowel resection
for bowel obstruction from carcinoid tumor.He has had previous transient ischemic attack. He hasbilateralcarotid disease with 60% to 70% stenoses.
GENERAL: Exam reveals an alert, orientedmale who has had recent weight loss.
VITAL SIGNS: Blood pressure 120/70, pulse80 per minute, respirations and temperature normal.
HEAD AND NECK: Normal except for faintbilateral carotid bruits. No lymphadenopathy.
HEART: Regular rhythm. No murmur.
ABDOMEN: Soft. No mass or tenderness. Bowelsounds present.
EXTREMITIES: He has palpable femoral andposterior tibial pulses bilaterally.
1. Severe coronary artery disease withrecent myocardial infarction, high-grade left main
coronary artery stenosis and occlusion ofright coronary artery, ischemic cardiomyopathy,
ventricular and supraventriculararrhythmias.
2. History of carcinomatosis, status postrecent bowel obstruction, previous colostomy for
3. Carotid occlusive disease with historyof previous transient ischemic attack.
RECOMMENDATION: The patient and his familyare fully aware of cardiac catheterization findings.
Dr. Kastanis has also discussed thesituation with the patient. The patient is in agreement withproceeding
with coronary artery bypass graft surgery,knowing that he has abdominal carcinomatosis. However, the
patient is expected to live for 2 to 3years from carcinoid tumor. His overall operative risk is around10%.
In view of his multiple medical problems, Iwill not aggressively pursue carotid angiogram prior to his
coronary artery bypass graft surgery.Informed consent has been obtained for the operation.
1. What diagnosis was madeat Crescent City Hospital?