history of present illness: this is a 67 year-old female with a history of type 2 diabetes, hypertension, peripheral vascular disease, coronary artery disease status post coronary artery bypass graft in , saphenous vein graft times three to left anterior descending coronary artery, obtuse marginal, posterior descending coronary artery, status post pci of the saphenous vein graft to left anterior descending coronary artery stent who presented with exertional chest pain as well as new rest anginal at night and increase in dyspnea on exertion times one week. she was initially evaluated at and found to have a positive troponin of 1.66. she was referred here to for catheterization. past medical history: 1. past cerebrovascular accident with no residual symptoms. 2. peripheral vascular disease. 3. type 2 diabetes. 4. coronary artery disease status post coronary artery bypass graft. 5. hypertension. 6. aortic stenosis with an area of .8. home medications: 1. toprol 50. 2. lisinopril 20. 3. hydrochlorothiazide 25. 4. aspirin 81. 5. plavix 75. 6. zetia. 7. glipizide 5 b.i.d. 8. metformin. 9. tegretol 100 t.i.d. 10. coumadin 10 mg four times a week, 7 mg three times a week. allergies: ampicillin. laboratory studies: cbc showed a white blood cell count of 11.2, hematocrit 34.0, platelet count 364. chem 7 showed a sodium of 134, potassium 4.3, chloride 100, co2 24, bun 26, creatinine 1.3. initial arterial blood gas was 7.42/37/71/95% saturation. electrocardiogram showed normal sinus rhythm at 93 with normal axis and intervals. st 1 mm depressions were noted in v5, v6 and 2. family history: mother has a history of diabetes mellitus as does sister. social history: married with two children. history of 50 pack year smoking history, but quit one year ago. no history of etoh or drug use. physical examination: vital signs temperature 99.6, heart rate 90, respiratory rate 24, blood pressure 130/44, 96% saturation on 2 liters nasal cannula, weight of 96 kilograms. alert and oriented woman with warm, dry skin. unable to adequately assess jvp secondary to habits. regular rate and rhythm s1 and s2 with a 2 out of 6 systolic ejection murmur that radiates to the carotids. bibasilar crackles were noted on auscultation. abdomen was soft, nontender, nondistended with no guarding or rigidity. trace extremity edema. hospital course: the patient was taken to the catheterization laboratory on . findings included right dominant coronary angiography, lmca 50% diffuse stenosis, left anterior descending coronary artery 80% stenosis proximally, filling well distally via its saphenous vein graft. left circumflex occluded after take off of obtuse marginal one. right coronary artery had mid portion occlusion. saphenous vein graft to posterior descending coronary artery was widely patent with excellent distal filling. saphenous vein graft to left anterior descending coronary artery had 99% in stent restenosis of ostium of graft and saphenous vein graft to left circumflex to obtuse marginal was occluded at the origin. impression of the catheterization included severe native three vessel coronary artery disease, old occlusion of the saphenous vein graft to left circumflex to obtuse marginal, widely patent saphenous vein graft to posterior descending coronary artery, and 99% in stent restenosis of the saphenous vein graft to left anterior descending coronary artery. severe aortic stenosis with a .8 area. severe left ventricular systolic dysfunction with an ef of 23%. marked elevation of resting left heart filling pressures. the intervention was successful brachytherapy and further stenting of the saphenous vein graft to left anterior descending coronary artery to reestablish flow. in the holding area after catheterization the patient had an episode of hematemesis. the bleeding did not clear following a 500 cc nasogastric lavage of normal saline. she was not complaining of any chest pain, shortness of breath and she was hemodynamically stable throughout. she was taken to the coronary care unit for further monitoring after her catheterization. she was given two large bore peripheral intravenouses and a liter of normal saline. she was typed and crossed with 4 units held for her and started on intravenous protonix b.i.d. her goal hematocrit was to keep her above 30. gastrointestinal was consulted. gastrointestinal recommended following hematocrit q 4 to 6 hours and to leave the nasogastric tube in place and to continue with the intravenous ppi. she was taken to esophagogastroduodenoscopy on friday and the findings included erythema, congestion, erosion and friability in the whole stomach compatible with an erosive gastritis. there was some blood in the fundus of the stomach. there was also erythema, congestion and friability in the proximal bulb compatible with a duodenitis. h-pylori titers were sent and she was recommended to stay on high dose ppi 40 mg po b.i.d. for four to six weeks. her hematocrit remained stable ni the range of 31 to 32. the nasogastric tube was pulled on the and the patient was felt stable enough to transfer to the floor. ctry was asked to evaluate the patient given the presence of significant aortic stenosis. they came and left recommendations that surgery would not be performed at the present time, but that she should follow up with dr. as an outpatient. the patient remained stable on the floor and was discharged to home on the hospital day number three. discharge condition: stable. discharge status: to home. discharge diagnoses: 1. coronary artery disease, in stent restenosis of saphenous vein graft to left anterior descending coronary artery graft. 2. aortic stenosis. 3. upper gastrointestinal bleed. major surgical/invasive procedures: cardiac catheterization with brachytherapy and stent placement and upper gastrointestinal endoscopy esophagogastroduodenoscopy performed . fop: the patient was told to follow up with her primary care physician in about week. she was told to continue taking a proton pump inhibitors for the next six weeks. a test for h-pylori was pending at the time of discharge. she was instructed to follow up with her primary care physician regarding this test. if positive she was instructed she would need additional medications i.e., triple therapy. she was instructed to make an appointment with her cardiologist dr. in and also to arrange a follow up to see dr. . discharge medications: 1. aspirin 325 mg q.d. 2. clopidogrel 75 mg q.d. 3. carbamazepine 100 mg t.i.d. 4. pantoprazole 40 mg b.i.d. for six weeks. 5. lisinopril 10 mg q.d. 6. metoprolol 12.5 mg b.i.d. 7. docusate 100 po b.i.d. 8. glucophage 850 b.i.d. 9. glipizide 5 b.i.d. , m.d. dictated by: medquist36 Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Angiocardiography of left heart structures Other endoscopy of small intestine Implantation or insertion of radioactive elements Insertion of drug-eluting coronary artery stent(s) Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Coronary atherosclerosis of autologous vein bypass graft Aortic valve disorders Other complications due to other cardiac device, implant, and graft Hemorrhage of gastrointestinal tract, unspecified