history of present illness: the patient is a 75 year old gentleman with a history of hypertension who presents with worsening dyspnea on exertion over the past two months. cardiac echocardiogram on , showed mild left ventricular hypertrophy, severely depressed ventricular systolic function, multiple area of hypo or akinesis, normal right ventricular function, trace aortic regurgitation and 2 to 3+ mitral regurgitation. subsequent exercise stress test showed dyspnea on exertion with no anginal type symptoms or interpretable electrocardiographic changes. the nuclear medicine portion showed severe reversible inferior wall and moderate reversible lateral wall perfusion deficits and left ventricular dilatation with stress. subsequent catheterization showed 50% left main and three vessel coronary artery disease with an ejection fraction of 20%. past medical history: significant for: 1. hypertension. 2. diabetes mellitus. 3. benign prostatic hypertrophy, status post transurethral resection of prostate in . medications: 1. lisinopril 20 milligrams p.o. q.d. 2. avandia 4 milligrams b.i.d. 3. lasix 20 milligrams q.d. 4. prandin 2 milligrams b.i.d. 5. folic acid q.d. 6. vitamin e 400 international units p.o. q.d. 7. toprol xl 50 milligrams q.d. 8. prilosec 20 milligrams p.o. q.d. allergies: no known drug allergies. physical examination: on admission, significant for a pulse of 80, blood pressure 152/78. the lungs are clear. the heart has a iii/vi murmur. the abdomen is soft. extremities are warm and well perfused without edema, palpable distal pulses. hospital course: the patient was admitted to the operating room where he underwent four vessel coronary artery bypass graft. he tolerated the procedure well and was taken to the cardiothoracic intensive care unit postoperatively. he was extubated on postoperative day number one and transferred to the floor. he started with physical therapy. he progressed rapidly. his lopressor dose was titrated to control his heart rate and blood pressure. of note, the foley was discontinued on postoperative day number two and the patient was unable to void so it was replaced the morning of postoperative day number three. he was started on flomax 0.4 milligrams p.o. q.d. and the foley was removed on the morning of . the patient was able to void successfully. he was cleared by physical therapy on , postoperative day number five and he was discharged to home. the patient was noted to have serous drainage from the proximal aspect of his right lower extremity saphenectomy site. the skin edges were nonerythematous and there was no evidence for infection. condition on discharge: stable. discharge diagnosis: coronary artery disease, status post coronary artery bypass graft times four. medications on discharge: 1. lopressor 75 milligrams p.o. b.i.d. 2. lasix 20 milligrams p.o. q.d. times five days. 3. kayciel 20 meq p.o. q.d. times five days. 4. aspirin 81 milligrams p.o. q.d. 5. avandia 4 milligrams p.o. b.i.d. 6. prandin 2 milligrams p.o. b.i.d. 7. reglan 10 milligrams p.o. q6hours times five days. 8. flomax 0.4 milligrams p.o. q.d. 9. percocet one to two tablets p.o. q4hours p.r.n. 10. colace 100 milligrams p.o. b.i.d. he is discharged home with services. the patient is to follow-up with doctor in three weeks and he is to follow-up with his primary care physician in one to two weeks. , m.d. dictated by: medquist36 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 Pure hypercholesterolemia Mitral valve disorders Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Personal history of tobacco use Retention of urine, unspecified Family history of ischemic heart disease