tokens: Admission Date : 2015-10-28 Discharge Date : 2015-11-13 Date of Birth : 1941-08-30 Sex : F Service : CARDIOTHORACIC Allergies : Tape / Benadryl Attending :Jordan U Kostohryz , M.D. Chief Complaint : Chest discomfort Major Surgical or Invasive Procedure : 2015-10-30 Left Carotid Stenting 2015-11-02 Coronary Artery Bypass Graft x 2 ( Lima to LAD , SVG to OM ) History of Present Illness : Ms. Bridge is a 74 y/o female admitted to outside hospital on 2015-10-21 with chest discomfort , vomiting and shortness of breath . Initial EKG showed ST depressions , but cardiac enzymes were not elevated . She eventually underwent a cardiac cath to assess coronary disease which revealed three vessel coronary artery disease . She was then transferred to The Hospital for Orthopedics for surgical intervention . Past Medical History : Coronary Artery Disease , Hypertension , Hyperlipidemia , Diabetes Mellitus , Hypothyroid , h/o Bilateral DVT 's ( on chronic coumadin therapy ), Pleural disorder ? Sarcoidosis , Gastritis , B12 deficiency , Chronic renal insufficiency , s/p Appendectomy , s/p Lap cholectomy , s/p Total abdominal hysterectomy Social History : Denies tobacco or ETOH use . Lives wth husband . Family History : Mother died of MI at age 55 . Brother w/ CAD since age 40 and died in 70 's after cardiac surgery . Son died at 14 d/t ASD . Physical Exam : Gen : NAD Neck : Supple , - JVD , - Bruits Heart : RRR - c/r/m/g Lungs : CTAB , coarse Abd : Soft , NT/NT + BS Ext : Cool , 1 + pedal pulses , - varicosities , - edema Neuro : A&O x 3 , MAE , non-focal Some rashes on ACW around EKG leads Pertinent Results : CNIS 10-29 : 1. 60-69% stenosis of the right internal carotid artery . 2. 80-99% stenosis of the left internal carotid artery . Echo 11-02 : PRE-BYPASS : Left ventricular wall thickness , cavity size , and systolic function are normal ( LVEF>55% ). Resting regional wall motion abnormalities include mild apical hypokinesis . The aortic valve leaflets ( 3 ) appear structurally normal with good leaflet excursion and no aortic regurgitation . The mitral valve appears structurally normal with trivial mitral regurgitation . There are complex (> 4 mm ) atheroma in the descending thoracic aorta . Mild tricuspid regurgitation . POST-BYPASS : Preserved Kindred / North Shore - ventricular systolic fxn . Trivial MR . Edith AI . Aorta intact . CT 11-04 : No acute intracranial hemorrhage . Findings consistent with small vessel ischemic changes . MRI would be more sensitive for the detection of acute infarction . CT angiogram demonstrates no stenosis or aneurysm in the intracranial circulation . Slight irregularity of the origin of the right vertebral artery may be atherosclerotic in nature . Normal contrast enhancement seen in the left common/internal carotid artery stent . Mild stenosis of the proximal right internal carotid artery . 4 mm left upper lobe lung nodule . In the absence of history of malignancy , this is statistically benign . One-year followup may be considered . CXR 11-06 : Allowing for technical changes , no major adverse interval change has occurred . Bibasilar subsegmental atelectasis together with bilateral pleural effusions appear relatively unchanged . The mediastinum appears unchanged . Left-sided subclavian line is unchanged in position . There is evidence of prior cardiac surgery . 2015-11-13 06:15 AM BLOOD WBC - 8.8 RBC - 2.79 * Hgb - 8.6 * Hct - 25.4 * MCV - 91 MCH - 30.9 MCHC - 33.8 RDW - 15.6 * Plt Ct - 583 * 2015-11-12 06:00 AM BLOOD WBC - 7.7 RBC - 2.73 * Hgb - 8.3 * Hct - 25.1 * MCV - 92 MCH - 30.4 MCHC - 33.1 RDW - 15.5 Plt Ct - 528 * 2015-11-13 06:15 AM BLOOD Plt Ct - 583 * 2015-11-13 06:15 AM BLOOD PT - 18.0 * PTT - 62.3 * INR(PT) - 1.7 * 2015-11-12 06:00 AM BLOOD PT - 15.5 * PTT - 62.4 * INR(PT) - 1.4 * 2015-11-11 05:45 AM BLOOD PT - 14.5 * PTT - 51.4 * INR(PT) - 1.3 * 2015-11-13 06:15 AM BLOOD Glucose - 96 UreaN - 20 Creat - 1.6 * Na - 141 K - 4.3 Cl - 106 HCO3 - 24 AnGap - 15 2015-11-12 06:00 AM BLOOD Glucose - 85 UreaN - 19 Creat - 1.6 * Na - 140 K - 4.4 Cl - 105 HCO3 - 24 AnGap - 15 2015-11-11 05:45 AM BLOOD Creat - 1.6 * K - 4.7 2015-10-28 03:30 PM BLOOD Glucose - 98 UreaN - 26 * Creat - 1.6 * Na - 140 K - 4.6 Cl - 104 HCO3 - 27 AnGap - 14 Brief Hospital Course : Ms. Bridge was admitted from OSH for coronary artery bypass surgery . She underwent usual pre-operative testing along with carotid ultrasound . CNIS revealed carotid stenosis and she ultimately underwent left carotid stenting by vascular surgery on 10-30 . Please see report for details . On 11-02 she was brought to the operating room where she underwent a coronary artery bypass graft x 2 . Please see operative report for surgical details . She tolerated the procedure well and was transferred to the CSRU for invasive monitoring in stable condition . Later on op day sedation was weaned , she awoke neurologically intact and was extubated . On post-op day one chest tubes were removed and beta blockers and diuretics were initiated . She was gently diuresed towards her pre-op weight . Also on this day she was transferred to the SDU . Early on post-op day two Ms. Bridge had an episode of aphasia . She underwent an immediate head CT and Neuro consult and was transferred back to the CSRU . CT was negative and she returned to baseline neuro status without deficits by arrival to CSRU . Neurology concluded episode was most concerning for TIA . Epicardial pacing wires were removed on post-op day four . After remaining stable in the CSRU for several days without change in neuro status she was transferred back to the SDU on post-op day four . She was then started on Heparin with transition to Coumadin ( goal INR of 2-3 secondary to h/o bilateral DVT 's). During entire post-op course she was followed by physical therapy for strength and mobility . She continued to improve steadily over the next several days without any other post-op complications . She was discharged on post-op day 11 . Medications on Admission : Meds at home : Coumadin , Levoxyl , Folate , Colace , Byetta , Verapamil , Lisinopril , Pravachol , Nexium , Lasix , Celexa Meds at transfer : Levoxyl , Celexa , Folate , Lopressor , Colace , RISS , B12 , Protonix , Lasix , Zocor , Verapamil , Lovenox , Lisinopril 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 :* 0 * 2. Pantoprazole 40 mg Tablet , Delayed Release ( E.C. ) Sig : One ( 1 ) Tablet , Delayed Release ( E.C. ) PO Q24H ( every 24 hours ). Disp :* 30 Tablet , Delayed Release ( E.C. )(s)* Refills :* 0 * 3. Levothyroxine 125 mcg Tablet Sig : One ( 1 ) Tablet PO DAILY ( Daily ). Disp :* 30 Tablet (s)* Refills :* 0 * 4. Simvastatin 40 mg Tablet Sig : One ( 1 ) Tablet PO DAILY ( Daily ). Disp :* 30 Tablet (s)* Refills :* 0 * 5. Citalopram 20 mg Tablet Sig : 0.5 Tablet PO DAILY ( Daily ). Disp :* 30 Tablet (s)* Refills :* 0 * 6. Clopidogrel 75 mg Tablet Sig : One ( 1 ) Tablet PO DAILY ( Daily ). Disp :* 30 Tablet (s)* Refills :* 0 * 7. Ferrous Gluconate 300 mg Tablet Sig : One ( 1 ) Tablet PO DAILY ( Daily ). Disp :* 30 Tablet (s)* Refills :* 0 * 8. Ascorbic Acid 500 mg Tablet Sig : One ( 1 ) Tablet PO BID ( 2 times a day ). Disp :* 30 Tablet (s)* Refills :* 0 * 9. Folic Acid 1 mg Tablet Sig : One ( 1 ) Tablet PO DAILY ( Daily ). Disp :* 30 Tablet (s)* Refills :* 0 * 10. Metoprolol Tartrate 25 mg Tablet Sig : One ( 1 ) Tablet PO BID ( 2 times a day ). Disp :* 60 Tablet (s)* Refills :* 0 * 11. Docusate Sodium 100 mg Capsule Sig : One ( 1 ) Capsule PO BID ( 2 times a day ). Disp :* 30 Capsule (s)* Refills :* 0 * 12. Coumadin 5 mg Tablet Sig : One ( 1 ) Tablet PO once a day : Check INR 11-15 with results called to Dr. Lynn . Disp :* 30 Tablet (s)* Refills :* 0 * 13. Tramadol 50 mg Tablet Sig : One ( 1 ) Tablet PO Q4-6H ( every 4 to 6 hours ) as needed . Disp :* 50 Tablet (s)* Refills :* 0 * 14. Lasix 40 mg Tablet Sig : One ( 1 ) Tablet PO once a day : 40 mg daily x 1 week then 40 mg every other day as prior to surgery . Disp :* 30 Tablet (s)* Refills :* 0 * Discharge Disposition : Extended Care Discharge Diagnosis : Coronary Artery Disease s/p Coronary Artery Bypass Graft x 2 Post-operative Transient Ischemic Attack Carotid Stenosis s/p Left Carotid Stenting PMH : Hypertension , Hyperlipidemia , Diabetes Mellitus , Hypothyroid , h/o Bilateral DVT 's, Pleural disorder ? Sarcoidosis , Gastritis , B12 deficiency , Chronic renal insufficiency , s/p Appendectomy , s/p Lap cholectomy , s/p Total abdominal hysterectomy Discharge Condition : good Discharge Instructions : Patient may shower , no baths . No creams , lotions or ointments to incisions . No driving for at least one month . No lifting more than 10 lbs for at least 10 weeks from the date of surgery . Monitor wounds for signs of infection . Please call with any concerns or questions . VVp Instructions : Dr. von Sampson in 4 weeks Dr Royer in 2-3 weeks Dr. Lynn in 1-2 weeks Peterson ver Vasquez MD 07-506 Completed by : Theresa Leonore NP 80-BXH 2015-11-13 @ 1100 Signed electronically by : DR. Ruby von der Smith on: WED 2015-12-09 3:34 PM ( End of Report )