Medical Text: Admission Date:  [**2177-3-12**]              Discharge Date:   [**2177-3-22**]

Date of Birth:  [**2109-6-26**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Shellfish

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

Major Surgical or Invasive Procedure:
[**2177-3-14**]
Coronary ARTERY BYPASS GRAFTING x3 with: Left Internal Mammary
Artery to Left Anterior Descending Artery,  Saphenous Vein Graft
to Obtuse Marginal Artery, Saphenous Vein Graft to Posterior
Descending Artery


History of Present Illness:
67 year old man with known coronary artery disease-s/p stents x
6(2004x5 and [**11-21**]) who developed exertional angina while
walking [**3-9**]. Angina resolved w/
rest after few minutes. Angina recurred [**3-11**], patient was brought
to [**Hospital **] Med Ctr where enzymes were negative. He had cardiac
catheterization which showed: tapering distal LM,70% osteal
LAD,90% mid RCA. LVEF 60% by LVgram.
He was then transferred to [**Hospital1 18**] for surgical management of his
coronary artery disease. At the time of transfer he was pain
free.


Past Medical History:
Coronary artery disease(PCI/stents x6), Hypertension,
HYPERCHOLESTEROLEMIA, CA- Left vocal cord(RT/chemo)[**3-20**]
PSH:Left knee arthroscopy, Left chest Portacath


Social History:
Works as administrator at [**University/College 33918**].
Married, 2 children.
Tob: Former smoker, quit 30 yrs ago.
ETOH: Drinks a few beers or cocktails per night.
No drugs


Family History:
Brother: MI at 60, uncle: MI at 50
Mother: htn

Physical Exam:
Pulse: Resp:  O2 sat:
B/P  Right:130/72    Left: 128/72
Height: 70"    Weight:175#

General:WDWN, NAD
Skin: Dry [] intact [x]
HEENT: PERRLA [x] EOMI [x]glasses
Neck:  Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x]  Irregular []  Murmur n
Abdomen: Soft [x] non-distended [x] non-tender [x]  bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]  Edema Varicosities:
None [x]
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        Right:n    Left:n


Pertinent Results:
Admission Labs:
[**2177-3-12**] 04:05PM   PT-11.7 PTT-23.8 INR(PT)-1.0
[**2177-3-12**] 04:05PM   PLT COUNT-199
[**2177-3-12**] 04:05PM   NEUTS-78.7* LYMPHS-9.6* MONOS-5.6 EOS-5.6*
BASOS-0.5
[**2177-3-12**] 04:05PM   WBC-6.9 RBC-3.93* HGB-14.0 HCT-38.2* MCV-97#
MCH-35.6* MCHC-36.6* RDW-13.5
[**2177-3-12**] 04:05PM   %HbA1c-5.2 eAG-103
[**2177-3-12**] 04:05PM   ALBUMIN-4.1 MAGNESIUM-1.7
[**2177-3-12**] 04:05PM   ALT(SGPT)-36 AST(SGOT)-24 LD(LDH)-148 ALK
PHOS-100 TOT BILI-2.0*
[**2177-3-12**] 04:05PM   GLUCOSE-123* UREA N-14 CREAT-1.0 SODIUM-137
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-27 ANION GAP-14
[**2177-3-12**] 04:33PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2177-3-12**] 04:33PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
Discharge Labs:


Radiology Report CHEST (PORTABLE AP) Study Date of [**2177-3-17**] 7:29
AM
Final Report: Comparison with study of [**3-15**], all of the
monitoring and support devices have been removed except for the
left subclavian catheter and the right IJ sheath. With the chest
tube removed, there is no evidence of pneumothorax. Residual
opacification at the left base is consistent with atelectasis
and effusion.

[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results  Measurements  Normal Range
Left Ventricle - Ejection Fraction:  55%  >= 55%
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: Color-flow imaging of the
interatrial septum raises the suspicion of an atrial septal
defect, but this could not be confirmed on the basis of this
study.
LEFT VENTRICLE: Normal regional LV systolic function. Overall
normal LVEF (>55%).
RIGHT VENTRICLE: Borderline normal RV systolic function.
AORTIC VALVE: Three aortic valve leaflets. No AS. Trace AR.
MITRAL VALVE: No MS. Mild (1+) MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: Small pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
Focused Intraoperative TEE during chest exploration for
post-operative bleeding.
Color-flow imaging of the interatrial septum raises the
suspicion of an atrial septal defect, but this could not be
confirmed on the basis of this study.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%).
Borderline normal RV free wall function.
There are three aortic valve leaflets. There is no aortic valve
stenosis. Trace aortic regurgitation is seen.
Mild (1+) mitral regurgitation is seen.
There is a small pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results.


Brief Hospital Course:
Mr [**Known lastname 732**] was transferred fro [**Hospital **] Med Ctr for surgical
management of his coronary artery disease. After the usual
pre-operative workup he was brought to the operating room for
coronary artery bypass grafting on [**2177-3-14**]. Please see the
operative report for details. In summmary he had: Coronary
Artery Bypass Grafting x3 with Lwft Internal Mammary Artery to
Left Anterior Descending Artery, Saphenous Vein Graft to Obtuse
Marginal Artery, and Saphenous Vein Graft to Posterior
Descending Artery. His cardiopulmonary bypass time was 51
minutes with a crossclamp time of 39 minutes. He tolerated the
operation well and post-operatively was transferred to the
cardiac surgery ICU in stable conditio. He remained
hemodynamically stable in the immediate post-op period. He woke
from anesthesia neurologically intact and was extubated on the
operative day.

On POD1 he continued to have significant drainage from his chest
tubes and was brought back to the operating room for mediastinal
exploration-no source of bleeding was found. He tolerated this
procedure well and was again returned to the cardiac surgery ICU
in stable condition. He recovered from anesthesia and was
extubated shortly after the surgery was completed. He remained
hemodynamically stable throughout this period.

All tubes lines and drains were removed per cardiac surgery
protocol. On POD 3 he was transferred from the ICU to the
stepdown floor for continued post-op care and recovery. Physical
therapy worked with the patient to advance his activities of
daily living and to improve strength and endurance.

POD # 4, Pt develope some drainage from his sternal incision. He
was started on IV Vancomycin. Betadine was cleanse TID was
started. from POD # [**4-19**], pts wound improved. He is to be
discharged on PO keflex x 10 days. His wound on DC is without
drainage.

On POD 10 was discharged home with visiting nurses. He is to
follow up with Dr [**Last Name (STitle) **] in 3 weeks, He has a sternal check
[**3-26**] on [**Hospital Ward Name **] 6. He is to follow up with his cardiologist, appt
made, He was also instructed to follow up with his PCP.


Medications on Admission:
Lisinopril 20mg daily,
Lipitor 80mg daily,
Plavix 75 mg [**Last Name (LF) **],
[**First Name3 (LF) **] 325mg daily,


Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
4. [**Last Name (un) 1724**]
Lisinopril 20mg daily,EcASA 325mg daily,Lopressor 25mg
[**Hospital1 **],Plavix 75mg daily,NTG prn,Lipitor 80mg daily

5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
8. potassium chloride 8 mEq Tablet Extended Release Sig: One (1)
Tablet Extended Release PO twice a day for 7 days.
Disp:*14 Tablet Extended Release(s)* Refills:*0*
9. Keflex 250 mg Capsule Sig: One (1) Capsule PO four times a
day for 10 days.
Disp:*40 Capsule(s)* Refills:*0*


Discharge Disposition:
Home With Service

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

Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Bypass Grafting x3
PCI/stents(6)
PMH:
Hypertension,
HYPERCHOLESTEROLEMIA,
CA- left vocal cord(RT/chemo)[**3-20**]
PSH:lt knee arthroscopy, LT chest Portacath


Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
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**]

**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) **] [**Name (STitle) **] on [**2177-4-10**] at 9AM at [**Hospital1 **]
Cardiologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5874**] on [**2177-4-16**] at 3PM

Please call to schedule appointments with your
Primary Care Dr [**Last Name (STitle) **],[**First Name3 (LF) 488**] J. [**Telephone/Fax (1) 8036**] in [**4-15**] weeks

You have a wound check scheduled for [**5-26**] at 1000 hrs,
please come to [**Hospital Ward Name **] 6 at this scheduled time. Thw midlevelers
will look at your wound to see if this is stable.

**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
Goal INR
First draw
Results to phone fax


Completed by:[**2177-3-22**]
ICD9 Codes: 4019, 2720