tokens: Admission Date : 2013-10-29 Discharge Date : 2013-11-04 Date of Birth : 1943-01-06 Sex : M Service : CARDIOTHORACIC Allergies : Patient recorded as having No Known Allergies to Drugs Attending : Angie CM Johnson , M.D. Chief Complaint : Coronary artery disease requiring surgical intervention Major Surgical or Invasive Procedure : CABG x 5 History of Present Illness : Mr. Andersen is a 71-year-old male with worsening anginal symptoms who underwent catheterization that showed severe three-vessel disease . He is presenting for revascularization . Past Medical History : DM2 - dx 'd at the age of 48 Arthritis HTN Tonsillectomy around the age of 10 Social History : Quit smoking 23 years ago , occasional ETOH , denies illicit drug use . Lives with wife , retired 12 years ago after working as electrician for Attleboro Donald Family History : Father died of colon cancer . Mother with pacemaker , alive at 91 years old . Physical Exam : Awake and alert , NAD HEENT : PERRLA , no carotid bruits CV : RRR , no M/R/G Lungs : CTA b/l Abd : Soft , NT/ND , NABS Ext : cool , no varicosities , 1+ pedal pulses Pertinent Results : 2013-10-29 11:37 AM BLOOD WBC - 11.4 *# RBC - 3.09 *# Hgb - 9.1 *# Hct - 27.5 *# MCV - 89 MCH - 29.5 MCHC - 33.3 RDW - 14.6 Plt Ct - 180 2013-10-29 11:37 AM BLOOD PT - 16.2 * PTT - 29.0 INR(PT) - 1.7 2013-10-29 11:37 AM BLOOD Plt Ct - 180 2013-10-29 01:09 PM BLOOD Glucose - 172 * UreaN - 11 Creat - 0.9 Na - 142 Cl - 111 * HCO3 - 22 2013-10-29 01:09 PM BLOOD Mg - 2.6 Brief Hospital Course : The patient was taken to the operating room on 2013-10-29 for a CABG x5 . Please see operative note for full details . The patient tolerated this procedure well . He was taken immediately post-operatively to the CSRU . He was extubated that night . The did well in the ICU . His central line and chest tubes were removed on post-op day #2 and was transferred to the floor in stable condition . On post-op day #3 , the patient 's pacing wires were removed , and his lopressor was started . On post-op day #4 , the patient failed the first of his void trials . He was seen and cleared by physical therapy . He was discharged home on post-op day #6 in stable condition with a foley catheter and leg bag . Medications on Admission : Avandia 8 mg daily Glipizide 10 mg bid Diovan 160 mg daily Metformin 500 mg two tabs bid Omeprazole 20 mg q PM Discharge Medications : 1. Docusate Sodium 100 mg Capsule Sig : One ( 1 ) Capsule PO BID ( 2 times a day ) as needed for constipation . Disp :* 60 Capsule (s)* Refills :* 2 * 2. 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 * 3. Oxycodone - Acetaminophen 5-325 mg Tablet Sig : 1-2 Tablets PO Q4H ( every 4 hours ) as needed for pain for 30 doses . Disp :* 30 Tablet (s)* Refills :* 0 * 4. Atorvastatin Calcium 10 mg Tablet Sig : One ( 1 ) Tablet PO DAILY ( Daily ). Disp :* 30 Tablet (s)* Refills :* 2 * 5. Rosiglitazone Maleate 8 mg Tablet Sig : One ( 1 ) Tablet PO DAILY ( Daily ). 6. Glipizide 10 mg Tablet Sig : One ( 1 ) Tablet PO BID ( 2 times a day ). 7. Tamsulosin 0.4 mg Capsule , Sust. Release 24 HR Sig : One ( 1 ) Capsule , Sust . Release 24 HR PO HS ( at bedtime ). Disp :* 30 Capsule , Sust. Release 24 HR (s)* Refills :* 0 * 8. Metoprolol Tartrate 25 mg Tablet Sig : 0.5 Tablet PO BID ( 2 times a day ). Disp :* 30 Tablet (s)* Refills :* 2 * 9. Furosemide 20 mg Tablet Sig : One ( 1 ) Tablet PO every twelve ( 12 ) hours . Disp :* 60 Tablet (s)* Refills :* 2 * 10. Pantoprazole Sodium 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 :* 2 * 11. Potassium Chloride 10 mEq Capsule , Sustained Release Sig : Two ( 2 ) Capsule , Sustained Release PO Q12H ( every 12 hours ). Disp :* 120 Capsule , Sustained Release (s)* Refills :* 2 * Discharge Disposition : Home with Service Discharge Diagnosis : Coronary artery disease Discharge Condition : Stable Discharge Instructions : Please return to the hospital or call Dr. Alvarado 's office if you experience chills or fever greater than 101 degrees F. Please call if you notice redness , swelling , or tenderness of your chest wound , or if it begins to drain pus . No heavy lifting or driving until follow up with Dr. Mullins . You may shower . Wash incision with mild soap and water , then pat dry . You will need to follow up with your primary care physician / urologist prior to removal of your urinary catheter . Followup Instructions : Provider : Mary , Francis Z. 739-488-1975 Call to schedule appointment . Please follow up in 1 month . Provider : Laurie , Paul G. ( 858 ) 481-2816 Call to schedule appointment . Please follow up in 1 week . Bernice Jessica MD 95-512 Completed by : Carol Lydia MD 27-960 2013-11-05 @ 0029 Signed electronically by : DR. Elizabeth GS Vega on : FRI 2013-12-06 12:28 PM ( End of Report )