tokens: Admission Date : 2016-04-05 Discharge Date : 2016-04-11 Date of Birth : 1948-10-18 Sex : M Service : Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS : This is a 67 - year-old male with a history of high cholesterol who was in his usual state of health until 2016-04-03 . He was raking leaves on 04-02 and then developed episodes of mid chest pain and burning which radiated to the left arm . That night he reportedly stopped breathing and was unresponsive . His wife gave him mouth-to-mouth resuscitation and he regained consciousness . He presented to an outside hospital with an acute inferior myocardial infarction and was treated with thrombolytic therapy . His troponin was 20 and he had EKG changes . He underwent catheterization on 2016-04-05 which revealed a left ventricular ejection fraction of 50% , no mitral regurgitation , insufficiency or hypokinesis . Left main coronary artery was narrowed 50-60% , left anterior descending coronary artery 70% proximally , right coronary artery dominant diseased up to 90% proximally in the midportion , 70% distally . The left circumflex coronary artery was 50% proximally , 90% obtuse marginal #3 . PAST MEDICAL HISTORY : 1. History of high cholesterol . 2. Hemorrhoidectomy . 3. Carotid disease . MEDICATIONS AT HOME : 1. Lipitor 20 mg p.o. q.d. 2. Aspirin 325 mg p.o. q.d. 3. Lopressor 25 mg p.o. b.i.d. 4. Plavix 75 mg p.o. q.d. which has been discontinued prior to surgery . FAMILY HISTORY : Positive for coronary artery disease . SOCIAL HISTORY : No cigarettes . PHYSICAL EXAMINATION : In general the patient was in no acute distress , afebrile , vital signs stable . HEENT : Normocephalic , atraumatic . Pupils equal , round and reactive to light . Extraocular movements intact . Nasopharynx benign . Neck : Supple with full range of motion , no lymphadenopathy nor thyromegaly . Carotids were 1+ bilaterally . Positive right carotid bruits . Lungs : Clear to auscultation bilaterally . Cardiovascular : Regular rate and rhythm , no murmurs . Abdomen : Positive bowel sounds , soft , nontender , nondistended , no masses , no hepatosplenomegaly . Extremities : Without cyanosis , clubbing or edema . Pulses were 2+ bilaterally throughout . Neurologic : Nonfocal . HOSPITAL COURSE : The patient was admitted to the hospital and on 2016-04-06 the patient underwent coronary artery bypass grafting x 4 with left internal mammary artery to the left anterior descending coronary artery , saphenous vein graft to the diagonal , saphenous vein graft to obtuse marginal , saphenous vein graft to right coronary artery , posterior descending coronary artery . The patient appeared to have tolerated the procedure and was transferred to the cardiac intensive care unit for postoperative management . He was started on beta blockers . The patient had pacing wires and chest tubes in place , both of which over the course of his stay were removed successfully . The patient did well postoperatively and was transported to the regular cardiac surgery floor where he tolerated a regular diet , ambulated well , did well with his activities of daily living . He was seen by physical therapy and cleared . They requested that he follow up in three to five weeks for endurance training , however then physical therapy followed him a number of times afterward and decided that he was in good condition and did not need further physical therapy . On 2016-04-11 the patient was in good condition and he is being discharged on a regular heart-healthy diet . He may observe regular activity although he should avoid strenuous activity and should not drive while on pain medications . He should follow up with Dr. Dushaj in four weeks . He should follow up with his cardiologist in two to three weeks and he should follow up with his primary care physician in one to two weeks . DISCHARGE MEDICATIONS : 1. Lasix 20 mg p.o. q. 12 . 2. Potassium 20 mEq p.o. q. 12 . 3. Colace 100 mg p.o. b.i.d. 4. Aspirin 325 mg p.o. q.d. 5. Percocet 1-2 tablets p.o. q. 4 p.r.n. pain . 6. Lopressor 12.5 mg p.o. b.i.d. Alexander S. Young , M.D. 29-418 Dictated By : Lila I Morgan , M.D. MEDQUIST36 D : 2016-04-11 10:48 T : 2016-04-11 10:59 JOB #: 75073 Signed electronically by : DR. Jose Kines on : TUE 2016-04-12 7:03 AM ( End of Report )