Age: 71.0
Sex: M
Vaccine: COVID19
Symptoms: Catheterisation cardiac abnormal, Chest pain, Coronary artery disease, Full blood count, Haematocrit decreased
Clinical narrative: MD  Last attending ? Treatment team   Discharge Summary MD (Physician) ? ? Cardiothoracic Surgery Expand All Collapse All CARDIOVASCULAR SURGERY DISCHARGE SUMMARY   This is MSN, APRN, dictating for Dr.    Patient was admitted on 8/5/2022 and is being discharged on 8/6/2022  to home in stable condition.   Admitting Diagnosis: 1. Triple vessel coronary artery disease  Past Medical History 2. Past Medical History: Diagnosis Date ? CAD (coronary artery disease)   ? Hypertension    2.     Discharge Diagnosis: 1. CAD 2. COVID diagnosis 3 weeks ago 3. Chronic renal disease stage 3--creatinine 1.9 prior to discharge   Consulting Services during hospitalization 1. N/a   History of Present Illness The patient is a 72 y.o. male, with a history of HTN who presented to cardiology with complaints of chest "burning" with activity. Patient underwent an elective heart cath today at facility which revealed multivessel CAD and transferred for CTS evaluation. Patient denies shortness of breath, peripheral edema, or dizziness. Was diagnosed with COVID on 7/29/22.  LHC revealed- 75% proximal LAD, 90% LCx, 100% RCA.    Hospital Course of Treatment Pt admitted to the facility and underwent evaluation. Due to recent COVID illness, recommendations are for surgery a total of 7 weeks from first positive result. Will discharge pt to return for surgery 9/6/2022.  No beta blocker therapy due to bradycardia.   Physical Exam   Blood pressure 132/70, pulse 69, temperature 97.6 °F (36.4 °C), temperature source Oral, resp. rate 18, height 6' 2" (188 cm), weight 104 kg (229 lb 3.2 oz), SpO2 100 %.   Heart:regular rate and rhythm, S1, S2 normal, no murmur, click, rub or gallop Lungs:clear to auscultation bilaterally Extremities:extremities normal, atraumatic, no cyanosis or edema Abdomen:soft, non-tender.  Bowel sounds normal.  No masses,  no organomegaly Wounds   CBC:   Lab Results Component Value Date/Time   WBC 6.4 08/05/2022 1445   RBC 4.29 08/05/2022 1445   HGB 13.8 08/05/2022 1445   HCT 39.2 08/05/2022 1445   MCV 91.3 08/05/2022 1445   MCH 32.1 08/05/2022 1445   MCHC 35.1 08/05/2022 1445   RDW 13.6 08/05/2022 1445   MPV 8.3 08/05/2022 1445   PLATELETCNT 184 08/05/2022 1445   BMP:   Lab Results Component Value Date/Time   SODIUM 134 08/06/2022 0719   POTASSIUM 4.5 08/06/2022 0719   CHLORIDE 102 08/06/2022 0719   CO2 26 08/06/2022 0719   GLUCOSE 103 08/06/2022 0719   BUN 38 08/06/2022 0719   CREATININE 1.9 08/06/2022 0719   CALCIUM 9.4 08/06/2022 0719   OSMOLALITY 278 08/06/2022 0719   BC 20 08/06/2022 0719       Discharge Medications:      Medication List   START taking these medications  aspirin 325 mg tablet Commonly known as: ASPIRIN Take 1 Tablet by mouth Once Daily. Start taking on: August 7, 2022   atorvastatin 10 mg tablet Commonly known as: LIPITOR Take 1 Tablet by mouth At bedtime for 90 days.   nitroglycerin 0.4 mg SL tablet Commonly known as: NITROSTAT Take 1 Tablet sublingually Every 5 minutes as needed for Chest pain.     CONTINUE taking these medications  ALDACTONE 50 mg tablet Generic drug: Spironolactone   levothyroxine 50 mcg tablet Commonly known as: SYNTHROID   lisinopriL 40 mg tablet Commonly known as: PRINIVIL Take 1 Tablet by mouth Twice a day.       Where to Get Your Medications   These medications were sent to Family Pharmacy    o aspirin 325 mg tablet o atorvastatin 10 mg tablet o lisinopriL 40 mg tablet o nitroglycerin 0.4 mg SL tablet