tokens: Admission Date : 2009-05-01 Discharge Date : Date of Birth : 1969-05-19 Sex : M Service : Surgery HISTORY OF PRESENT ILLNESS : The patient is a 39 year-old gentleman admitted on 2009-05-01 to the Jewish Memorial Hospital referred from South Cove Community Health Center . He is a 39 year-old gentleman with hyperlipidemia and smoking who presented with acute onset of chest pain since five in the morning with radiation to the left arm and nausea . Symptoms resolved spontaneously . He was taken to the Cath Lab at the Pinewood , Norfolk that evening where a stent procedure to the RCA was complicated by guidewire entrapment inside of a stent requiring CT surgery to do a thoracotomy with bypass and excision of the wire . The case was complicated by an episode of coffee ground emesis and a bleed from femoral access site prior to CT surgery . Gastroenterology was consulted and they recommended Protonix and felt it was due to peptic ulcer disease . PAST MEDICAL HISTORY : 1. Hepatitis B . 2. Hypercholesterolemia . 3. Fatty liver resolved . MEDICATIONS AT HOME : Relatively unknown other than Lipitor . ALLERGIES : He had no known drug allergies . SOCIAL HISTORY : He smokes one pack per day . He works as a jeweler . He lives at home with his wife . FAMILY HISTORY : Not significant for coronary artery disease . Please note the patient is only Caucasian speaking and information is second hand . HOSPITAL COURSE : The patient was diagnosed as having an acute myocardial infarction . The patient was taken emergently to the operating room on 2009-05-02 for his CABG , right coronary endarterectomy , removal of RCA stents and retrieval of the aortic guidewire . Postoperatively he did well and was transferred to the Cardiac Surgery Intensive Care Unit where he was on pressor support of Neo-Synephrine and he was extubated . The patient slowly weaned off Neo-Synephrine as tolerated . He was transferred to the floor on 2009-05-04 . His chest tube had been discontinued . Upon arrival to the floor the patient 's wires were discontinued on 2009-05-05 and his Foley catheter was discontinued . The patient was seen by Physical Therapy . His electrolytes were repleted and the patient was discharged home on 2009-05-06 after tolerating a level V . MEDICATIONS : His prescriptions shall include 1. Lopressor 25 milligrams po bid . 2. Lipitor 20 milligrams po q HS . 3. Niferex 150 milligrams caplet one cap per day . 4. Protonix 40 milligrams po q day . 5. Colace 100 milligrams po bid . 6. Percocet one to two tablets q four H prn for pain . He will get 60 of those . 7. Plavix 75 milligrams po q day times three months . 8. Aspirin 325 milligrams po q day . 9. Lasix 20 milligrams po times 30 days . 10. KCL 20 milliequivalents po q d times three days . DISCHARGE FOLLOW UP : The patient is to follow up with Dr. Debra Oneal , his PCP and his cardiologist in 3 weeks . Saul N. Keehne , M.D. Dictated By : Shirley Y Waler , M.D. MEDQUIST36 D : 2009-05-06 11:12 T : 2009-05-06 11:34 JOB #: 20629 Signed electronically by : DR. William Spencer on : WED 2009-05-06 12:20 PM ( End of Report )