allergies: amoxicillin / niaspan extended-release attending: chief complaint: chest pain major surgical or invasive procedure: - cabgx4 (left internal mammary artery to left anterior descending artery, and sequential reverse saphenous vein graft to the posterior descending artery, and the posterior left ventricle branch artery and reverse saphenous vein graft to the obtuse marginal artery). history of present illness: 59 year old male with known coronary artery disease, htn, dyslipidemia, peripheral vascular disease s/p right femoral stent/left angioplasty, right carotid endarterectomy presents to osh with unstable angina. previous cath =showed 100%occluded prox rca, and a plaquing nonsignificant obstructive lesion in the left main coronary. lexiscan showed fixed inferior defect, ef=56% with inf.hypokinesis. cardiac cath repeated at osh revealed 60% left main/3vd. he was transferred to for evaluation of coronary revascularization. past medical history: past medical history: coronary artery disease s/p mi ', htn, dyslipidemia, peripheral vascular disease s/p right femoral stent/left angioplasty, carotid endarterectomy , anxiety, depression, tobacco abuse. past surgical history: s/p right superficial femoral artery angioplasty with stent/left angioplasty, right carotid endarterectomy . social history: occupation:unemployed cigarettes: smoked no yes last cigarette _____ hx:1ppd x >40-45 yrs-hx of failed treatment-chantix/nicotine patch other tobacco use:denies etoh: < 1 drink/week drinks/week >8 drinks/week family history: father mi (+)mi at 60, mother (+) cad->stents physical exam: pulse: resp: o2 sat: b/p right: left: height:68" weight:165lbs general:a&ox3, nad skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur grade ______ abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema _____ varicosities: none neuro: grossly intact pulses: femoral right: left: dp right: 1+ left:1+ pt : left: radial right: left: carotid bruit none right: left: pertinent results: echo pre-bypass: no spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. no atrial septal defect is seen by 2d or color doppler. the left ventricular cavity size is normal. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. there are simple atheroma in the aortic arch. there are complex (>4mm) atheroma in the descending thoracic aorta. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. there is no aortic valve stenosis. no aortic regurgitation is seen. trivial mitral regurgitation is seen. there is a very small pericardial effusion. dr. was notified in person of the results at time of surgery. post-bypass: the patient is a paced. the patient is on no inotropes. biventricular function is unchanged. mitral regurgitation is mild. tricuspid regurgitation is unchanged. the aorta is intact post-decannulation. brief hospital course: mr. was admitted to the on for surgical management of his coronary artery disease. he was worked-up in the usual preoperative manner, osh report of carotid duplex ultrasound was obtained which showed left ica stenosis 50-69%. (right carotid endarterectomy performed ). a transthoracic echocardiogram was performed which showed a normal ejection fraction with a mild mitral regurgitation. on , he was taken to the operating room where he underwent coronary artery bypass grafting to four vessels (left internal mammary artery to left anterior descending artery,and sequential reverse saphenous vein graft to the posterior descending artery, and the posterior left ventricle branch artery and reverse saphenous vein graft to the obtuse marginal artery) with dr..please refer to operative report for further surgical details.cross-clamp: time is 80 minutes. pump time 88 minutes. he tolerated the procedure well and was transferred to the cvicu intubated and sedated. postoperatively mr. neurologically intact and was extubated. he weaned off nitroglycerin drip and was started on beta-blocker/statin/aspirin and diuresis. all lines and drains were discontinued per protocol. on pod#1 he was transferred to the step down unit for further monitoring. physical therapy was consulted for strength and mobility. continued to make good progress and was cleared for discharge to home with vna on pod #4. all f/u appointments were advised. no vna services were arranged as he did not have insurance coverage for vna services. medications on admission: asa 325(1),fish oil 1000(2),lorazepam 1 (2), bupropion 200(1),metoprolol 150(1), amlodipine 10(1),gemfibrozil 600(2), lovastatin 20(1), citalopram 40(1), vit d 1000 units(1), vit b12 1000 mcg (1), potassium chloride 20 meq(1) ntg 0.4 prn discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) for 1 months. disp:*60 capsule(s)* refills:*0* 2. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day) for 2 weeks. disp:*28 tablet(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:*1* 4. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*65 tablet(s)* refills:*0* 5. multivitamin tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*1* 6. citalopram 20 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*1* 7. omega-3 fatty acids capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*1* 8. gemfibrozil 600 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*1* 9. bupropion hcl 100 mg tablet extended release sig: two (2) tablet extended release po qam (once a day (in the morning)). disp:*60 tablet extended release(s)* refills:*1* 10. cholecalciferol (vitamin d3) 1,000 unit tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*1* 11. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*1* 12. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*1* 13. cyanocobalamin (vitamin b-12) 500 mcg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*1* 14. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*1* 15. lasix 20 mg tablet sig: two (2) tablet po once a day for 7 days. disp:*14 tablet(s)* refills:*0* 16. potassium chloride 20 meq tablet, er particles/crystals sig: two (2) tablet, er particles/crystals po once a day for 6 days. disp:*12 tablet, er particles/crystals(s)* refills:*0* 17. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* discharge disposition: home discharge diagnosis: coronary artery disease s/p mi ' hypertension dyslipidemia peripheral vascular disease s/p right femoral stent/left angioplasty carotid endarterectomy anxiety depression tobacco abuse discharge condition: alert and oriented x3 nonfocal ambulating with steady gait incisional pain managed with oral analgesia incisions: sternal - healing well, no erythema or drainage leg right - healing well, no erythema or drainage. edema trace discharge instructions: 1) please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage. 2) please no lotions, cream, powder, or ointments to incisions. 3) each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) no driving for approximately one month and while taking narcotics. driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) no lifting more than 10 pounds for 10 weeks 6) please call with any questions or concerns **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments surgeon: dr. on at 1:15pm in the medical office building , wound check on at 10:00am cardiologist:dr on at 4:30pm please call to schedule appointments with your : primary care dr. in weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Diagnostic ultrasound of heart Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Other and unspecified hyperlipidemia Old myocardial infarction Family history of ischemic heart disease Atherosclerosis of native arteries of the extremities, unspecified Acute respiratory failure following trauma and surgery