allergies: patient recorded as having no known allergies to drugs attending: chief complaint: acute mi/unstable angina major surgical or invasive procedure: - emergent cabgx4 (left internal mammary->left anterior descending artery, vein graft->obtuse marginal artery with sequential to second obtuse marginal artery, vein graft->right coronary artery). history of present illness: this 49-year-old patient with sudden onset 1-hour history of chest pain presented to the outside hospital where a subsequent angiogram showed acute thrombosis of the right coronary artery with inferior myocardial infarction. an attempt was made at the outside hospital to open this artery but was unsuccessful and the patient was transferred emergently for urgent coronary artery bypass grafting. the patient remained hemodynamically stable during transfer and during induction and intraoperative transesophageal echocardiogram showed preserved left ventricular function. along with the thrombosis of the right coronary artery, he had 60% left main stenosis lesion with subsequent critical lesions in the left anterior descending artery and the obtuse marginal arteries. there is no significant past medical history. past medical history: hyperlipidemia cad mi social history: current tobacco abuse. family history: none known physical exam: vs: 99.2, 100/52, 82sr, 20, 95%ra gen: nad, overweight lungs: ctab cv: rrr, no murmur or rub abd: nabs, non-tender, non-distended ext: warm,trace edema sternal incision: c/d/i, no erythema or drainage evh: c/d/i, no erythema or drainage pertinent results: echo pre-cpb: patient brought emergently to or direct from . unable to pass probe into stomach. no spontaneous echo contrast is seen in the left atrial appendage. rv shows mild global free wall hypokinesis. mild septal and inferior hypokinesis, but overall good lv systolic fxn. there are simple atheroma in the descending thoracic aorta. 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 is no pericardial effusion. post-cpb: patient is on phenylephrine, av-paced. now able to get gastric views. improved biventricular systolic fxn., although septum and inferior wall still slightly hk. no mr, no ai. aorta intact. 05:50am blood wbc-9.3 rbc-3.23* hgb-9.4* hct-27.6* mcv-86 mch-29.0 mchc-33.9 rdw-13.8 plt ct-164 05:50am blood glucose-115* urean-14 creat-0.7 na-137 k-3.8 cl-101 hco3-27 angap-13 05:50am blood mg-2.0 brief hospital course: mr. was admitted to the on via for emergent surgical revascularization. he was taken directly to the operating room where he underwent coronary artery bypass grafting to four vessels. he did have some perioperative ventricular dysrhythmia and amiodarone was started. please see operative note for details. postoperatively he was taken to the intensive care unit for monitoring. within 24 hours, he awoke neurologically intact and was extubated. on postoperative day one, he was transferred to the step down unit for further recovery. he was gently diuresed towards his preoperative weight. aspirin, beta blockade and a statin were started. the physical therapy service was consulted for assistance with his postoperative strength and mobility. chest tubes and pacing wires were discontinued without complication. by the time of discharge on pod 4 the patient was ambulating freely, the wound was healing, and pain was controlled with oral analgesics. medications on admission: lipitor discharge medications: 1. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*0* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) for 1 months. disp:*60 capsule(s)* refills:*0* 3. 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* 4. hydromorphone 2 mg tablet sig: 1-2 tablets po q3h (every 3 hours) as needed. disp:*60 tablet(s)* refills:*0* 5. atorvastatin 10 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 6. furosemide 20 mg tablet sig: two (2) tablet po once a day for 2 weeks. disp:*28 tablet(s)* refills:*0* 7. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po twice a day for 2 weeks. disp:*28 tab sust.rel. particle/crystal(s)* refills:*0* 8. ranitidine hcl 150 mg tablet sig: one (1) tablet po twice a day for 1 months. disp:*60 tablet(s)* refills:*0* 9. amiodarone 200 mg tablet sig: two (2) tablet po bid (2 times a day): 400mg 2x/day for 3 days, then 200mg 2x/day for 1week, then 200mg/day. disp:*120 tablet(s)* refills:*0* discharge disposition: home with service facility: hospice and vna discharge diagnosis: cad s/p cabgx4 acute mi tobacco abuse hyperlipidemia discharge condition: good discharge instructions: 1) monitor wounds for signs of infection. these include redness, drainage or increased pain. in the event that you have drainage from your sternal wound, please contact the at (. 2) report any fever greater then 100.5. 3) report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) no lotions, creams or powders to incision until it has healed. you may shower and wash incision. gently pat the wound dry. please shower daily. no bathing or swimming for 1 month. use sunscreen on incision if exposed to sun. 5) no lifting greater then 10 pounds for 10 weeks. 6) no driving for 1 month or while taking narcotics for pain. 7) call with any questions or concerns. followup instructions: please follow-up with dr. in 1 month. ( please follow-up with dr. in 2 weeks. please follow-up with dr. in 2 weeks. call all providers for appointments. md Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Diagnoses: Coronary atherosclerosis of native coronary artery Tobacco use disorder Paroxysmal ventricular tachycardia Other and unspecified hyperlipidemia Acute myocardial infarction of inferolateral wall, initial episode of care