Medical Text: Admission Date:  [**2162-5-16**]              Discharge Date:   [**2162-5-21**]

Date of Birth:  [**2101-7-30**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Angina

Major Surgical or Invasive Procedure:
[**2162-5-17**]: CABGx4 LIMA-> LAD, RSVG-> Diagonal, Posterior
Descending Artery, Obtuse marginal
[**2162-5-19**]: Right Atrial lead placement


History of Present Illness:
60yo man with known coronary disease (AMI in [**2143**] and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]
LCx [**2155**]). Doing well until last week when he developed angina
initially with exertion then progressed to rest angina. Each
episode was releived with SL NTG, no episode lasting more than 5
minutes. He presented to cardiologist for treatment. He was
admitted to MWMC, a cardiac catheterization revealed 3 vessel
disease. He was transferred to [**Hospital1 18**] for coronary bypass
grafting.
Cardiac Catheterization: Date: [**2162-5-11**]    Place: MWMC
-LAD- chronic total occlusion proximally(distal filling via
collaterals)
-RCA- chronic total occlusion of non-dominant RCA 90%
-LCx- new complex 90% stenosis of prox LCx involving the
bifurcation of the LCx proper and large OM2.
Old stent in LCx is widely patent
-mod LV systolic dysfx, with anterior, apical, and infero-apical
AK and reduced EF 30%
LVEDP 36mmHg
No valvular dz


Past Medical History:
CAD-(AMI [**2143-7-3**], [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LCx [**6-/2155**])
Cardiomyopathy- EF 35-45% depending on study
Ventricular tachycardia s/p AICD [**8-/2155**]
Atrial flutter s/p ablation [**8-/2155**]
Hypertension
Dyslipidemia
Insulin dependent diabetes Mellitus
Obesity
Conduction disease-LAFB
Peripheral vascular disease s/p Right fem-[**Doctor Last Name **] bypas [**3-/2161**]
Left leg claudication
Right thigh tumor s/p radiation and excision [**2141**]'s


Social History:
Race: caucasian
Last Dental Exam:
Lives with: wife
Occupation: [**Name2 (NI) 56028**] owns company
Tobacco: 2ppd x20 yrs quit [**2143**]
ETOH: occaisional


Family History:
Father died 50yo cirrhosis, mother died 42yo MI


Physical Exam:
Pulse: 58  Resp: 16   O2 sat: 97%-RA
B/P  Right: 124/76   Left:
Height:  5'[**62**]"   Weight: 259 lbs

General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck:  Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x]  Irregular []  Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x]  bowel sounds
+
[x]
Extremities: Warm [x], well-perfused [x]  Edema -none
Varicosities: None [x]. Well healed right vein harvest site.
Neuro: Grossly intact
Pulses:
Femoral      Right: +2  Left:+2
DP           Right:+2   Left:+2
PT           [**Name (NI) 167**]: +2  Left:+2
Radial       Right: +2  Left:+2

Carotid Bruit   none     Right:  +2  Left:+2


Pertinent Results:
[**2162-5-17**]:
Prebypass
The left atrium is dilated. No spontaneous echo contrast is seen
in the body of the left atrium or left atrial appendage. No
spontaneous echo contrast is seen in the body of the right
atrium.
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is severely dilated.
There is moderate regional left ventricular systolic dysfunction
with hypokinesis of the apex and septum. Overall left
ventricular systolic function is mildly depressed (LVEF=30-35%).
The estimated cardiac index is depressed (<2.0L/min/m2). Focal
abnormalities are seen in the mid and apical anteroseptal wall,
apical anterior wall, mid and apical inferoseptal wall, apical
inferior wall. NO thrombus was seen in LV apex.
Right ventricular chamber size and free wall motion are normal.
The descending thoracic aorta is mildly dilated.
The aortic valve leaflets (3) are mildly thickened with focal
calcification of the non-coronary cusp which moves poorly. There
is a minimally increased gradient consistent with minimal aortic
valve stenosis. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**1-3**]+) mitral regurgitation is seen. There is no mitral valve
prolapse or flail segments. There is no pericardial effusion.
Postbypass
The patient is A-paced and on a phenylephrine infusion.
Biventricular systolic function is unchanged. Mitral
regurgitation remains mild-to-moderate. The thoracic aorta is
intact post decannulation.

[**2162-5-20**] 05:00AM BLOOD WBC-10.9 RBC-3.73* Hgb-11.2* Hct-31.7*
MCV-85 MCH-30.1 MCHC-35.4* RDW-13.9 Plt Ct-114*
[**2162-5-20**] 05:00AM BLOOD Glucose-151* UreaN-19 Creat-0.7 Na-135
K-3.9 Cl-100 HCO3-28 AnGap-11
[**2162-5-16**] 05:00PM BLOOD ALT-66* AST-55* LD(LDH)-206 AlkPhos-73
TotBili-0.3

Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2162-5-17**] where the patient underwent Coronary
artery bypass graft x 4. See operative note for details.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
The Electrophysiology team was consulted now due to non
capturing atrial lead after permanent pacemaker was initially
interrogated and epicardial wires were removed. Ventricular lead
and ICD were functioning appropriately. The right atrial lead
was revised on [**5-19**] without complication. He is to follow up the
device clinic at [**Hospital1 **] in 2 weeks - operative note was given
to patient to bring to follow up appointment. The patient was
neurologically intact and hemodynamically stable on no inotropic
or vasopressor support. Beta blocker was initiated and the
patient was gently diuresed toward the preoperative weight.
Lisinopril was restarted for better blood pressure. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes were discontinued without complication on post
operative day 3. The patient was evaluated by the physical
therapy service for assistance with strength and mobility.  By
the time of discharge on POD 4 the patient was ambulating
freely, the sternal and pacer pocket wound was healing and pain
was controlled with oral analgesics. He is to continue on 1 week
of antibiotics per EP s/p atrial lead placement.  The patient
was discharged home with VNA services in good condition with
appropriate follow up instructions.  All follow up appointments
were arranged.

Medications on Admission:
Lisinopril 20'
Atenolol 100'
Vytorin [**10/2131**] QHS
Fenofibrate 200'
ASA 325'
NTG-sl/PRN
Insulin-NPH 22u QAM/24u QPM- followed by [**Last Name (un) **]
Insulin- Humalog SS
MVI
Calcium 600'

Plavix - last dose:[**2162-5-12**]

Allergies: NKDA


Discharge Medications:
1. fenofibrate 160 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
2. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*1*
4. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*100 Tablet(s)* Refills:*0*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
9. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
12. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 7 days.
Disp:*7 Tablet, ER Particles/Crystals(s)* Refills:*0*
13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
15. NPH insulin human recomb 100 unit/mL Suspension Sig: One (1)
 Subcutaneous twice a day: Take 22 units in AM and 24 units in
PM.
Disp:*QS 1 month * Refills:*0*
16. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 1110**] VNA

Discharge Diagnosis:
Coronary Artery Disease
CAD-(AMI [**2143-7-3**], [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LCx [**6-/2155**]),Cardiomyopathy- EF
35-45% Ventricular tachycardia s/p AICD [**8-/2155**], Atrial flutter
s/p ablation [**8-/2155**], Hypertension, Dyslipidemia,Insulin
dependent diabetes Mellitus, Obesity, Conduction disease-LAFB,
Peripheral vascular disease s/p Right fem-[**Doctor Last Name **] bypas [**3-/2161**], Left
leg claudication, Right thigh tumor s/p radiation and excision
[**2141**]'s


Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
1+ Edema


Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart

No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**


Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] on [**6-10**] at 1:45pm [**Telephone/Fax (1) 170**]
Cardiologist: Dr. [**Last Name (STitle) 1295**] on [**6-14**] at 3:30pm
EP [**Hospital 19721**] Clinic at [**Hospital1 **] in [**1-3**] weeks: Call for appointment
-
[**Telephone/Fax (1) 6256**]
Wound check appointment in [**Hospital **] Medical office building
[**Telephone/Fax (1) 170**]
 Date/Time:[**2162-5-26**] 12:00


Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 27187**] in [**4-6**] weeks [**Telephone/Fax (1) 3658**]
Follow up with [**Hospital **] [**Hospital 982**] Clinic to be arranged by patient

**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**




Completed by:[**2162-5-24**]
ICD9 Codes: 4111, 2859, 4019, 2720