Discharge Provider:   Primary Care Provider: MD Admission Date: 8/15/2022 Discharge Date: 9/16/2022  PRESENTING PROBLEM: Coronary arteriosclerosis in native artery [I25.10] Aortic valve disease [I35.9] Arteriosclerotic coronary artery disease [I25.10] Aortic valve stenosis, critical [I35.0] Coronary artery arteriosclerosis [I25.10] Aortic stenosis, severe [I35.0]   HOSPITAL COURSE: The patient was seen in the office and was found to be a candidate for Coronary artery bypass grafting x1 using endoscopically harvested left saphenous vein, aortic valve replacement, intra op TEE, TEE INTRAOPERATIVE. The procedure was performed on 8/15/2022. The procedure went well and the patient was transferred to the CVRU per routine. 8/19: Patient needs to be pushed as far as pulmonary rehab and activity. Renal panel Q 6 hrs. CI 2.4-3.6 The patient developed covid pneumonia as well as aifb with rvr and hypotension. She required critical care for several days. 8/21: ECHO 8/18 with reduced EF of 20%. May need AHFconsult. Now improved will tfer to 7hc. 8/22: ECHO 8/18 with reduced EF of 20%. AHF consult. WBC trending up- UA positive- culture ordered. Afib RVR this am, Amio bolus/gtt. Continue Midodrine for hypotension.  8/23: cefepime started per ID for urine culture 8/24: holding tube feeds for abdominal distention, encourage oral intake, continue bilateral pleural drains. 8/25: continue lasix per AHF recommendations, keep bilateral pleural drains, out of bed to chair today 8/26: out of covid isolation, started ambulating in room. Bilateral pleural tubes remain. Corpak remains with tube feeds on hold. Eating more - continue calorie count. 8/27: Remove chest tube after walk today, if output remains low, continue calorie count, increase activities.  8/28: Continue nocturnal tube feeding. Anticipate discharge to rehab in 1-2 days.  8/29: C/o lower abdominal pain. UA positive- per discussion with Dr. will wait for culture results prior to treating with ABX, since WBC is going down and patient is not febrile. KUB showed nonobstructive supine bowel gas pattern. Transfuse 1 unit of PRBC today. Weight trending up. Cardiology managing heart failure, started Milrinone today. IR central PICC ordered. Continue nocturnal tube feeding. Poor oral calorie intake. 8/30: Bleeding from chest tube and PICC line site. Hold Heparin. WBC trending up, obtain blood cultures. Heart failure managed by cardiology.  8/31: Patient now NSR, WBCs continue to trend up. CXR ordered. Monitor blood and urine cultures Discuss leukocytosis with ID and attending.  9/1: Intermittent a-fib, Patient continues to not tolerate tube feeds, Starting with TPN and lipids today, d/c corpak. Vascular consulted. IR consulted for thoracentesis and draining fluid collection of the left psoas muscle.  9/2: Nutrition recommending jejunal corpak instead of TPN and lipids. Jejunal corpak placed today. Hgb 7 this morning - 2PRBCs given plus extra dose of lasix Bed side right thoracentesis performed by CTS PA - 800ml off, asked RN to send culture of the fluid. Discussed psych consult for depression medication - not interested at this time. Discuss having the patient go outside if she can tolerate sitting up - Patient was interested in this but was not able to due to procedures. IR planning on aspiration of left psoas fluid collection.   9/4: psychiatry consulted at the request of a daughter from out of town - remeron started. Tube feeds running at 20ml/hr around the clock due to not tolerating 40ml/hr. 9/5: ancef started for left knee endo site warmth and erythema 9/6: Amiodarone and milrinone drips per AHF. Replace K+, phos and Mag. Warmth/erythema of left knee EVH site improving. Heart failure managing diuretics and antihypertensives. ECHO completed, EF- 45%, no pericardial effusion. 9/7: Continue Ancef for warmth/erythema of left knee EVH site, order written for patient to o outside with RN  9/9: Left knee looking much improved. Restart calorie count due to patient telling IR she did not want PGJ. Disccused the importance of getting her to rehab and the need for PGJ. Patient agreed to get PGJ if she is not  able to take in enough calories during the calorie count.   9/10: Continue Calorie count. PJG pending for Monday. Needs PT/OT 9/11:  continues to have poor oral intake. TF via corpak. Anticipate PGJ Monday  9/12: PGJ placed 9/13:Continue calorie count. continues to have poor oral intake. TF via corpak. Patient c/o pain after PGJ placement. Plan for d/c to rehab on Thursday  9/14: IR to remove tunneled PICC today, continue tube feeding. Anticipate discharge to rehab tomorrow. 9/15: Patient is ready for SAR discharge, when bed available.  9/16: Patient is in stable condition. Patient was c/o pain at the PGJ site, CT completed by IR, no concerns noted. She denies shortness of breath or chest pain. Sternal incision clean dry and Intact. Having bowel movements. Discharge to rehab today. Discharge instructions given. CXR from today reviewed with Dr., right pleural effusion, No intervention required.