allergies: patient recorded as having no known allergies to drugs attending: chief complaint: dyspnea on exertion major surgical or invasive procedure: - redo sternotomy, aortic valve replacement(21mm st. regent mechanical valve), mitral valve repair(28mm ce mitral band), cabgx1 (saphenous vein->obtuse marginal artery). history of present illness: 72 year old man with known as who underwent an avr (tissue prosthesis) in 11/98. he was hospitalized in with dyspnea. a stress stes was suggestive of ischemia with atrial fibrillation. a cardiac catheterization was performed which showed single vessel coronary artery disease and significant aortic stenosis and insufficiency. he is now referred for surgical management. past medical history: coronary artery disease prosthetic aortic stenosis mitral regurgitation s/p coronary stenting s/p aortic valve replacement chronic atrial fibrillation hyperlipidemia hypertension benign prostatic hypertrophy social history: retired. lives with wife in , ma. never smoked. drinks 1 glass of wine daily. family history: uncle with mi at age 57 physical exam: discharge: vss steable. 107/57 af rate 80-90 lungs:clear cor: irregularly irregular, no murmur or rub abd: soft, non-tender, non-distended ext: trace edema evh: c/d/i, no erythema or drainage sternal incision: c/d/i, no erythema or drainage, sternum stable pertinent results: carotid ultrasound no stenosis of the right carotid. 60-69% left carotid stenosis. echo prebypass 1.no atrial septal defect is seen by 2d or color doppler. 2.overall left ventricular systolic function is normal (lvef>55%). 3. right ventricular chamber size and free wall motion are normal. 4. there are simple atheroma in the descending thoracic aorta. 5. a bioprosthetic aortic valve prosthesis is present. moderate to severe (3+) aortic regurgitation is seen. 6. the mitral valve leaflets are moderately thickened. moderate to severe (3+) mitral regurgitation is seen. 7. moderate tricuspid regurgitation is seen. 8. dr. was notified in person of the results on at 1100 am. post bypass 1. patient is v paced and receiving an infusion of epinephrine and phenylphrine. 2. biventricular systolic function is unchanged. 3. there is an annuloplasty ring seen in the mitral position. it appears well seated. immediately post bypass there was 3+ mitral regurgitation that was 2+ at the end of the case. peak gradient across the mitral valve is 9 mm hg. there is no . 4. mechanical prosthesis seen in the aortic position. the valve appears well seated and the leaflets move well. there is trace central aortic insufficiency. washing jets typical for this type of valve are also seen. peak gradient across the aortic valve is 11 mm hg. 5. aorta is intact post decanulation. 6. dr notified of the above post bypass findings. 09:10am blood wbc-7.5 rbc-3.43* hgb-10.5* hct-29.4* mcv-86 mch-30.6 mchc-35.7* rdw-14.8 plt ct-230 07:25am blood glucose-97 urean-16 creat-1.0 na-138 k-3.8 cl-101 hco3-31 angap-10 09:10am blood mg-2.1 05:40am blood pt-22.1* ptt-32.7 inr(pt)-2.1* brief hospital course: mr. was admitted to the on for surgical management of his aortic valve and coronary artery disease. heparin was started as a bridge to surgery as he had stop his coumadin five days prior to admission. on , mr. was taken to the operating room where he underwent a redo aortic valve replacement with a . mechanical valve, a mitral valve repair and coronary artery bypass grafting to one vessel. please see operative note for details. postoperatively he was taken to the intensive care unit for monitoring. he weaned from bypass on neosynephrine and epinephrine. within 24 hours, he awoke neurologically intact and was extubated. pressors were weaned easily and he remained stable. on postoperative day one, mr. was transferred to the step down unit for further recovery. coumadin was resumed for af and his mechanical valve. he was gently diuresed towards his preoperative weight. the physical therapy service was consulted for assistance with his postoperative strength and mobility. sotalol was resumed for his af and beta blockade and digoxin were added. his af rate was well controlled, he felt well and was ready for discharge on 11.18 arrangements were made for his coumadin to be regulated by dr. as preoperatively. the inr goal is 2.5-3.5. medications, restrictions and follow up were discussed with the patient prior to going home. medications on admission: digitek 250mcgm, coumadin 5/2.5, plavix 75, sotalol 120, quinipril 20, lipitor 10, synthroid 0.125, amoxicillin prn discharge medications: 1. influen tr-split vac (pf) 45 mcg/0.5 ml syringe sig: one (1) ml intramuscular asdir (as directed) for 1 days. 2. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 4. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*50 tablet(s)* refills:*0* 5. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. levothyroxine 125 mcg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 8. warfarin 2.5 mg tablet sig: as directed tablet po once a day: inr 2.5-3.5. disp:*100 tablet(s)* refills:*2* 9. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 10. potassium chloride 20 meq packet sig: one (1) packet po daily (daily). disp:*30 packet(s)* refills:*2* 11. sotalol 80 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 12. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 13. acetaminophen 325 mg tablet sig: 1-2 tablets po every hours as needed for pain. discharge disposition: home with service facility: vna discharge diagnosis: coronary artery disease prosthetic aortic insufficiency s/p aortic valve replacement chronic atrial fibrillation s/p coronary stenting hyperlipidemia hypertension benign prostatic hypertrophy 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 weeks. please follow-up with dr. in 3 weeks. () please call for appointments wound clinic in 2 weeks Procedure: Extracorporeal circulation auxiliary to open heart surgery Diagnostic ultrasound of heart Open and other replacement of aortic valve (Aorto)coronary bypass of one coronary artery Open heart valvuloplasty of mitral valve without replacement Diagnoses: Coronary atherosclerosis of native coronary artery Mitral valve disorders Unspecified essential hypertension Unspecified acquired hypothyroidism Atrial fibrillation Aortic valve disorders Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Percutaneous transluminal coronary angioplasty status Occlusion and stenosis of carotid artery without mention of cerebral infarction Other and unspecified hyperlipidemia Mechanical complication due to heart valve prosthesis Long-term (current) use of anticoagulants Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation Abrasion or friction burn of face, neck, and scalp except eye, without mention of infection Fall from other slipping, tripping, or stumbling