Medical Text: Admission Date:  [**2170-9-19**]              Discharge Date:   [**2170-9-25**]

Date of Birth:  [**2099-5-27**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Dyspnea on exertion and fatigue

Major Surgical or Invasive Procedure:
[**2170-9-19**] Coronary artery bypass graft x 4 (Left internal mammary
artery to diagonal, saphenous vein graft to left anterior
descending, saphenous vein graft to obtuse marginal, saphenous
vein graft to posterior descending artery)

History of Present Illness:
71 year old male who presented to his PCP for [**Name Initial (PRE) **] routine visit
with complaints of recent onset fatigue, dyspnea on exertion,
exertional throat discomfort and left arm. He denied any rest
pain but reports the discomfort and dyspnea occur with minimal
activities such as showering. He was found to be hypertensive
and was started on Atenolol 25mg daily. His EKG was normal and
he was sent for a nuclear stress test. He underwent a nuclear
stress test on [**2170-8-1**] which revealed inferolateral ischemia and
a moderate inferior, inferolateral, and posterolateral perfusion
abnormality. He is now refereed for cardiac catheterization. He
is now being referred to cardiac surgery for revascularization.

Past Medical History:
Hypertension
Right rotator cuff tear
Compound fracture of left arm/plated as a child
Benign colon polyps
Arthritis
s/p right rotator cuff repair
s/p repair if left arm fracture, plated

Social History:
Race:Caucasian
Last Dental Exam:"a very long time ago", does not recall when
Lives with:Wife
Contact:[**Name (NI) **] (wife) Phone #[**Telephone/Fax (3) 74913**]
Occupation:self employed painter
Cigarettes: Smoked no [x]
Other Tobacco use:denies
ETOH: stopped drinking in [**12-20**]
Illicit drug use:denies

Family History:
No premature coronary artery disease

Physical Exam:
Pulse: 56 Resp:13  O2 sat:97/RA
B/P  Right:173/82    Left:164/76
Height:5'9"     Weight:200 lbs

General: NAD, WG, WN
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 [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x]  bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]  Edema [] none_
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral      Right: 2+  Left: 2+
DP           Right: 1+  Left: 1+
PT           [**Name (NI) 167**]: 1+  Left: 1+
Radial       Right: 2+  Left: 2+

Carotid Bruit        Right:    Left:
no bruits

Pertinent Results:
[**2170-9-25**] 06:35AM BLOOD WBC-10.9 RBC-2.94* Hgb-9.3* Hct-26.3*
MCV-89 MCH-31.6 MCHC-35.3* RDW-13.5 Plt Ct-261
[**2170-9-24**] 06:20AM BLOOD WBC-13.4* RBC-3.27* Hgb-10.1* Hct-28.7*
MCV-88 MCH-31.0 MCHC-35.3* RDW-14.2 Plt Ct-197
[**2170-9-25**] 06:35AM BLOOD Na-139 K-4.0 Cl-99
[**2170-9-24**] 06:20AM BLOOD Glucose-118* UreaN-26* Creat-0.9 Na-139
K-4.0 Cl-98 HCO3-31 AnGap-14
[**2170-9-23**] 05:00AM BLOOD UreaN-25* Creat-0.9 Na-137 K-4.3 Cl-99

Brief Hospital Course:
Mr. [**Known lastname **] was a same day admit and on [**9-19**] was brought to the
operating room where he underwent a Coronary artery bypass graft
x4 (left internal mammary artery to the diagonal and saphenous
vein grafts to the left anterior descending, obtuse marginal,
and posterior descending arteries) with Dr.[**First Name (STitle) **].
CARDIOPULMONARY BYPASS TIME:104 minutes. CROSS-CLAMP TIME:93
minutes. Please see operative report for further surgical
details. Following surgery he was transferred to the CVICU
intubated and sedated in critical but stable condition. Later
this day he was weaned from sedation, awoke neurologically
intact and extubated without incident. He weaned from pressor
support and beta blocker/Statin/Aspirin and diuresis was
initiated. Chest tubes and epicardial pacing wires were removed
per protocol. POD#1 he was transferred to the step-down unit for
further monitoring. Physical Therapy was consulted for
evaluation of strength and mobility. During his postoperative
course he developed atrial fibrillation and was treated with
beta blockers and amiodarone. Anticoagulation was initiated with
Coumadin. He developed a phlebitis from IV Amio and was placed
on a course of Keflex x 7 days. This was slowly improving. His
pulmonary status waxed and waned with a strong productive cough
and wheezing, which improved by the time of discharge. He
continued nebulizer treatments. CXR showed small bilateral
pleural effusions with atelectasis, no infiltrate or density.
His pulmonary status slowly improved by his day of discharge. On
POD 4 he developed a tender erythematous right knee and was
treated with colchicine for presumed gout. This had improved by
the time of discharge and the colchicine was discontinued.  On
POD 6 he was afebrile, ambulating with assistance, tolerating a
full po diet and his wounds were healing well. On POD 6 he was
discharged to Lifecare Center of [**Location 15289**] in stable
condition. All follow up appointments were advised.


Medications on Admission:
ATENOLOL 25 mg Daily
ASPIRIN 325 mg daily
FISH OIL-DHA-EPA  1,200 mg-144 mg-216 mg Daily
MV-FA-CA-FE-MIN-LYCOPEN-LUTEIN [A THRU Z HIGH POTENCY] 400
mcg-162 mg-18 mg-300 mcg-250 mcg Tablet Daily
NAPROXEN SODIUM [ALEVE]PRN

Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/temp.
6. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
7. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): x 1 week then 200 [**Hospital1 **] x 1 week then 200 mg daily
directed by caridologist.
8. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
10. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.

11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours).
12. ipratropium bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).
13. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for coughing .
14. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days: For right arm phlebitis.
15. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 14
days.
16. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 14 days.

17. warfarin 2 mg Tablet Sig: Two (2) Tablet PO ONCE (Once):
Give 4 mg on [**9-26**] then as directed for INR goal 2.0-2.5 for A
fib.


Discharge Disposition:
Extended Care

Facility:
Life Care Center of [**Location 15289**]

Discharge Diagnosis:
Coronary artery disease s/p coronary artery bypass graft x 4
Past medical history:
Hypertension
Right rotator cuff tear
Compound fracture of left arm/plated as a child
Benign colon polyps
Arthritis
s/p right rotator cuff repair
s/p repair if left arm fracture, plated

Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
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**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**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. [**First Name (STitle) **] on [**10-29**] at 1:15pm, #[**Telephone/Fax (1) 170**]
Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] on [**9-25**] at 2:00pm

Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **]. Nikolaos Michalacos in [**4-17**] weeks

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

Labs: PT/INR for Coumadin ?????? indication atrial fibrillation
Patient to be given 4 mg Coumadin on [**2170-9-25**]
Goal INR 2.0-2.5
First draw [**2170-9-26**]
Please arrange follow up with PCP or cardiologist prior to
discharge from rehab


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]

Completed by:[**2170-9-25**]
ICD9 Codes: 4111, 5119, 5180, 4019