Medical Text: Admission Date:  [**2164-4-23**]              Discharge Date:   [**2164-4-27**]

Date of Birth:  [**2096-1-7**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest pain and shortness of breath

Major Surgical or Invasive Procedure:
[**2164-4-23**] Coronary artery bypass grafting x3 with left internal
mammary artery to left anterior descending artery and reverse
saphenous vein graft to the posterior descending artery and the
obtuse marginal artery.

History of Present Illness:
68 year old male has a history of an MI about 25 years ago. He
has been treated with medication since then. He has been doing
well over the years until about 3 weeks ago when he started to
notice some diaphoresis, shortness of breath and right sided
chest discomfort that has occurred with exertion such as yard
work or taking out the trash. His symptoms resolve with rest. He
also had one episode of chest pain, diaphoresis and back pain
that occurred at rest after a large meal. This episode lasted a
little longer than the other episodes and prompted the patient
to contact Dr. [**Last Name (STitle) 1270**]. He was sent for a stress echo which
was abnormal and referred for a cardiac catheterization. He is
was found to have three vessel disease and is now being referred
to cardiac surgery for revascularization.

Past Medical History:
diabetes type II -diagnosed [**2160**]; controlled on oral agents
hyperlipidemia
hypertension
MI [**2138**]
psoriasis

Social History:
Race:Caucasian
Last Dental Exam:[**1-/2164**]
Lives with:Wife
Contact:[**Name (NI) **] (wife) Phone #[**Telephone/Fax (1) 90854**]
Occupation:Retired from the FDA as a field investigator and
consultant
Cigarettes: Smoked no [] yes [x] Hx:smoked 2ppd for 28 years and
quit [**2138**]
Other Tobacco use:denies
ETOH: < 1 drink/week [x]  [**12-27**] drinks/week [] >8 drinks/week []
Illicit drug use:denies

Family History:
Premature coronary artery disease- unknown-adopted


Physical Exam:
Pulse:61 Resp:16  O2 sat:100/RA
B/P  Right:138/86    Left:135/74
Height:6'2"     Weight:230 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 [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x]  bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]  Edema [x] _____
Varicosities: (L)LE superficial varicosities
Neuro: Grossly intact [x]
Pulses:
Femoral      Right:   Left:
DP           Right:2+   Left:2+
PT           [**Name (NI) 167**]:   Left:
Radial       Right:   Left:

Carotid Bruit -none appreciated, pulses  Right:2+  Left:2+

Pertinent Results:
[**2164-4-23**] Echo: PRE-BYPASS: No spontaneous echo contrast is seen in
the body of the left atrium or left atrial appendage. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
top normal/borderline dilated. There is mild regional left
ventricular systolic dysfunction with hypokinesis of the basal
to distal inferoseptal and anteroseptal walls. Overall left
ventricular systolic function is mildly depressed (LVEF= 50-55
%). Right ventricular chamber size and free wall motion are
normal. There are simple atheroma in the aortic arch. There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **]
was notified in person of the results at time of surgery.
POST-BYPASS: The patient is in sinus rhythm. The patient is on
no inotropes. Biventricular function is unchanged. Mitral
regurgitation is unchanged. The aorta is intact
post-decannulation.

[**2164-4-27**] 04:44AM BLOOD WBC-11.7* RBC-3.00* Hgb-9.8* Hct-28.3*
MCV-94 MCH-32.5* MCHC-34.5 RDW-14.0 Plt Ct-323
[**2164-4-27**] 04:44AM BLOOD Plt Ct-323
[**2164-4-27**] 04:44AM BLOOD Glucose-121* UreaN-22* Creat-1.0 Na-139
K-3.8 Cl-102 HCO3-28 AnGap-13
[**2164-4-27**] 04:44AM BLOOD Mg-2.3

COMPARISON:  [**2164-4-25**] at 10:45 a.m.

FINDINGS:  As noted previously, there is a similar-sized left
apical
pneumothorax.  The left chest tube has been removed in the
interim.  Left
basilar atelectasis remains.  The cardiac silhouette and
mediastinal contours
are unchanged.  Median sternotomy wires are unchanged.

IMPRESSION:
Unchanged small left apical pneumothorax, status post left chest
tube removal.



Brief Hospital Course:
Mr. [**Known lastname **] 68 yr old male with history of MI developed
worsening chest pain, underwent cath which revealed significnat
CAD. He was seen by the cardiac surgery service and accepted for
CABG. He was a same day admit and on [**4-23**] was brought directly to
the operating room where he underwent a coronary artery bypass
graft x 3. Please see operative note for surgical details.
Following surgery he was transferred to the CVICU for invasive
monitoring in stable condition. Later this day he was weaned
from sedation, awoke neurologically intact and extubated. He was
weaned from Neo overnight and was started on beta-blocker POD#1.
He was diuresed towards his preoperative weight. POD#1 he
transferred to the step down unit for further monitoring. He
continued to progress well on the floor. Physical Therapy was
consulted for evaluation of his strength and mobility. The
remainder of his postop course was essentially uneventful. He
was cleared for discharge to home with VNA services on POD#4.
Follow-up appts arranged.


Medications on Admission:
ATENOLOL 50 mg Daily
LIPITOR 20 mg Daily
PLAVIX 75 mg Daily (started on [**2164-4-14**]), LD [**4-17**]
DILTIAZEM HCL 240 mg Daily
ENALAPRIL MALEATE takes 10mg qam, 5mg qhs
HYDROCHLOROTHIAZIDE 25 mg Daily
METFORMIN 1,000 mg [**Hospital1 **]
NITROGLYCERIN 0.4 mg Tablet PRN
Aspirin 325mg Daily
Centrum Silver Multivitamin 1 tablet daily

Discharge Medications:
1. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 2 weeks.
Disp:*60 Tablet Extended Release(s)* Refills:*2*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
Disp:*1 * Refills:*2*
6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 2
weeks.
Disp:*14 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 86**] VNA

Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 3
Past medical history:
diabetes type II -diagnosed [**2160**]; controlled on oral agents
hyperlipidemia
hypertension
MI [**2138**]
psoriasis

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
Wound Check: [**2164-5-8**] 10:00
Surgeon: Dr. [**Last Name (STitle) **] on [**2164-5-31**] @ 1pm
Cardiologist/PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1270**] [**Telephone/Fax (1) 1144**]
Date/Time:[**2164-5-15**] 10:30

**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:[**2164-4-27**]
ICD9 Codes: 2724, 4019, 412