tokens: Admission Date : 2017-06-13 Discharge Date : 2017-06-17 Date of Birth : 1956-02-17 Sex : M Service : CARDIOTHORACIC Allergies : Patient recorded as having No Known Allergies to Drugs Attending:Jordan U Kostohryz , M.D. Chief Complaint: recent mild angina with exertion Major Surgical or Invasive Procedure : emergency CABG X 3 ( 2017-06-13 )( LIMA to LAD , SVG to ramus , SVG to OM ) History of Present Illness : 61 yo African-American-Hispanic male had abnormal EKG found as part of pre-op eval. for ventral hernia repair . Had subsequent abnormal stress test and pefusion imaging showed EF 38% with perfusion defects . Echo prior to scheduled cath showed mild LVH , inferior HK , EF 40% , mild MR , mild LAE . Cath at Kindred/North Shore today showed 80% LM lesion with normal LAD , CX , RCA . Severe systolic HTN also noted . Transferred in urgently for cabg with Dr. Howard . Past Medical History : ventral hernia HTN elev. chol. right facial droop with metal plate secondary to GSW to face right nephrectomy Social History : current smoker Family History : not given Physical Exam: Not done , taken to OR direct from ambulance transfer . Pertinent Results: 2017-06-14 02:06AM BLOOD WBC - 9.4 RBC - 3.61* Hgb - 10.4* Hct - 29.9* MCV - 83 MCH - 28.8 MCHC - 34.8 RDW - 14.3 Plt Ct - 154 2017-06-17 05:14AM BLOOD Hct - 25.2* 2017-06-14 02:06AM BLOOD Plt Ct - 154 2017-06-13 08:05PM BLOOD PT - 13.6* PTT - 33.3 INR ( PT ) - 1.2* 2017-06-17 05:14AM BLOOD UreaN - 25* Creat - 1.0 K - 3.9 2017-06-15 02:02PM BLOOD Mg - 2.1 FINAL REPORT TWO VIEW CHEST , 2017-06-17 COMPARISON : 2017-06-14 . INDICATION : Status post coronary bypass surgery . There has been removal of a Swan-Ganz catheter and placement of a right internal jugular vascular catheter , with the tip terminating in the proximal right atrium just below the junction with the superior vena cava . Cardiac and mediastinal contours are stable in the postoperative period . Previously reported interstitial edema has resolved . There has been interval improvement in left basilar atelectasis . Right basilar atelectasis has slightly worsened . Bilateral pleural effusions are unchanged . IMPRESSION : 1. Vascular catheter tip terminates in proximal right atrium . 2. Bibasilar minor atelectasis , worse on the right and improved on the left . Persistent pleural effusions . DR. John S. Beauchamp Approved : SAT 2017-06-17 8:20 PM Procedure Date:2017-06-17 PRE-CPB : The left atrium is mildly dilated . No spontaneous echo contrast is seen in the body of the left atrium . No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage . No mass/thrombus is seen in the left atrium or left atrial appendage . No atrial septal defect is seen by 2D or color Doppler . There is mild symmetric left ventricular hypertrophy with normal cavity size . There is mild symmetric left ventricular hypertrophy . The left ventricular cavity size is normal . No left ventricular aneurysm is seen . There is mild regional left ventricular systolic dysfunction . Overall left ventricular systolic function is mildly depressed . There is no ventricular septal defect . Resting regional wall motion abnormalities include mild inferior hypokinesis . Right ventricular chamber size and free wall motion are normal . The right ventricular cavity is mildly dilated . There are simple atheroma in the aortic root . There are simple atheroma in the ascending aorta . There are simple atheroma in the aortic arch . There are simple atheroma in the descending thoracic aorta . There are three aortic valve leaflets . The aortic valve leaflets are mildly thickened . No masses or vegetations are seen on the aortic valve . There is no aortic valve stenosis . Trace aortic regurgitation is seen . The mitral valve leaflets are mildly thickened . No mass or vegetation is seen on the mitral valve . Trivial mitral regurgitation is seen . There is no pericardial effusion . POST-CPB : Preserved LV systolic function on phenylephrine . LVEF now 50% . Trace MR , AI as described . Normal aortic contours . I certify that I was present for this procedure in compliance with HCFA regulations . Electronically signed by Tracy Kimball , MD , Interpreting physician Brief Hospital Course: Admitted directly to OR from ambulance transfer and underwent cabg x3 with Dr. Howard on 06-13 . Transferred to the CSRU in stable condition on phenylephrine and propofol drips . Extubated early the next morning and chest tubes removed . Gentle diuresis and beta blockade started , and he was transferred to the floor to begin increasing his activity level . Foley removed on POD #2 and had scattered rales with temp 101.2 . Afebrile the next day and pacing wires removed without incident . He made excellent progress and was discharged to home with VNA services on POD #4 . He is to follow up with providers as per discharge instructions . Medications on Admission : bisoprolol 5 mg daily crestor 20 mg daily HCTZ 25 mg daily lisinopril 40 mg daily Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig : One ( 1 ) Tablet PO BID ( 2 times a day ) . Disp : *60 Tablet( s )* Refills : *2* 2. Potassium Chloride 10 mEq Capsule , Sustained Release Sig : Two ( 2 ) Capsule , Sustained Release PO Q12H ( every 12 hours ) for 7 days . Disp : *28 Capsule , Sustained Release( s )* Refills : *0* 3. Docusate Sodium 100 mg Capsule Sig : One ( 1 ) Capsule PO BID ( 2 times a day ) . Disp : *60 Capsule( s )* Refills : *2* 4. Ranitidine HCl 150 mg Tablet Sig : One ( 1 ) Tablet PO BID ( 2 times a day ) . Disp : *60 Tablet( s )* Refills : *2* 5. 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* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig : 1-2 Tablets PO every 4-6 hours as needed for pain . Disp : *50 Tablet( s )* Refills : *0* 7. Rosuvastatin 20 mg Tablet Sig : One ( 1 ) Tablet PO DAILY ( Daily ) . Disp : *30 Tablet( s )* Refills : *2* 8. Furosemide 20 mg Tablet Sig : One ( 1 ) Tablet PO BID ( 2 times a day ) for 7 days . Disp : *14 Tablet( s )* Refills : *0* Discharge Disposition: Home with Service Discharge Diagnosis: CAD HTN ventral hernia right nephrectomy s/p right facial plating Discharge Condition : good Discharge Instructions : may shower , no bathing or swimming for 1 month no creams , lotions or powders to any incisions no driving for 1 month no lifting > 10 # for 10 weeks A. Instructions : with Dr. Matthew in 2-3 weeks with Dr. Dellinger in 2-3 weeks with Dr. les Gokey in 4 weeks Curtis van den Moreno MD 07-506 Completed by : Scott Robert NP 80-AUM 2017-06-29 @ 1121 Signed electronically by : DR. Barbara van de Tate on : FRI 2017-07-28 1:55 PM ( End of Report )