history of present illness: ms. is a 40 year-old female with a history of unstable angina. she had presented with substernal chest pressure on exertion that began to occur at rest as well. she ultimately underwent a cardiac catheterization on showing a heart with an ef of approximately 70%, left main disease of 70% stenosis, left anterior descending of 30% stenosis, left circumflex of 40% and the obtuse marginal was 30%. given the degree of severity of the left main disease in the setting of the substernal chest pressure and unstable angina the patient was therefore scheduled for coronary artery bypass graft. off pump coronary artery bypass graft was done secondary to the fact that the patient has a history of nephrotic syndrome and was at risk for coagulopathy, stroke, etc. past medical history: significant for hepatitis b and c treated with interferon. last treatment was two years ago. cryoglobulinemia as well as nephrotic syndrome. she does have a history of chronic low back pain and is on roxicet chronically and there is a question of past history of intravenous drug abuse. allergies: lipitor and atenolol for which she gets a rash. there is a questionable allergy to contrast dye. admission medications: not available. hospital course: she was brought to the operating theater on by dr. where she underwent an elective two vessel coronary artery bypass graft off pump. the first graft was the left internal mammary coronary artery to the left anterior descending coronary artery. the second graft was the left radial to the oblique marginal. this was done due to the poor size of the saphenous vein grafts that were mapped preoperatively. the patient tolerated the procedure well and was on nitroglycerin drip, propofol and phenylephrine. she was brought to the critical care unit and upon arrival to the unit was noted to go into v fibrillation arrest. therefore given the proximity to the operating room her chest was immediately opened to rule out any tamponade physiology from anastomotic leak or bleed. it was found that she did have blood in the pericardial space. she was therefore brought to the operating room for an immediate redo coronary artery bypass graft. she underwent a two vessel coronary artery bypass graft at this time including a saphenous vein graft that was utilized to the left anterior descending as well as to the diagonal in a sequential manner. the intraoperative findings were significant for a dissected left internal mammary coronary artery graft. the left radial to the obtuse marginal artery was still intact, however. after leaving the second procedure the patient was intubated. she had received four 8 units of packed cells in her resuscitation and eight units of fresh frozen platelets as well as 3 packs of platelets. she was on milrinone, amiodarone, diltiazem and neo when she left the operating theatre. in the intensive care unit she was placed on vancomycin and gentamycin for the fact that her chest had to be opened at the bedside. on postoperative day one she was still extubated. she was hemodynamically stable. her postoperative hematocrit was significant for 30 and this was post transfusion, because the immediate postop was 22 and she had received the previously mentioned blood products. her coagulation panel was normal. her k was 5.0, bun and creatinine were 13 and .7, magnesium was 1.6 and that was repleted. she was weaned to extubation. her swan-ganz catheter was left in place for hemodynamic monitoring. chest x-ray on postoperative day one had shown patchy infiltrates with a right pleural effusion. by postoperative day number two the patient's diet was advanced. she was started on lasix, aspirin and antihyperlipidemic therapy. additionally a beta blocker was added. the patient's swan-ganz catheter was placed to cvl. she did well over the next day and ultimately was transferred to the floor on postoperative day number three. at this point she was being maintained on a morphine pca with toradol and percocet for breakthrough pain. given her chronic opioid dependence she did have significant issues of tolerance and therefore was ultimately referred to the acute pain service who had recommended to use oxycodone 20 mg po q 3 to 4 hours prn as well as morphine sulfate intermediate release 15 mg po b.i.d. her laboratories on postoperative day number five were significant for a hematocrit of 26 that was stable. potassium 4.1, bun and creatinine were 24 and .8 and the remainder of her electrolytes were within normal limits. on postoperative day five was also marked by the onset of persistent substernal chest discomfort, pressure and tightness. electrocardiogram was done at that time, which showed no significant changes for ischemia or infarction. no dysrhythmia. she remained in sinus. her chest x-ray at that time additionally showed a left pleural effusion. the right pleural effusion was stable. the left pleural effusion was somewhat new. there was also evidence of a loculated retrosternal collection in the right upper hemithorax, however, this was stable. her vital signs remained afebrile and hemodynamically stable throughout her entire hospital course once she was out of the intensive care unit setting. the acute pain service ultimately titrated her medication regimen for pain control to the aforementioned regimen. discharge medications: lasix 20 mg po q.a.m., colace 100 mg po b.i.d., aspirin 325 mg po q day, plavix 75 mg po q day, oxycodone 10 to 20 mg po q 3 to 4 prn, msir 15 mg po b.i.d., imdur 30 mg po q day, lopressor 50 mg po b.i.d., amiodarone 400 mg po t.i.d., ibuprofen 600 mg po q 4 to 6 prn as well as oxazepam 15 to 30 mg po q.h.s. prn. the patient's vital signs at the time of discharge, she was afebrile with a temperature maximum of 99.0, pulse 70 and sinus, 123/68 blood pressure, 97% on room air saturation. she was in no acute distress. her sternum was stable. there was no erythema or exudate. her staples were intact. her lungs were clear with decreased breath sounds left greater then right. no crackles were present. her lower extremities were nonedematous, warm and well profuse. she had palpable pulses distally in the dorsalis pedis pulse and posterior tibial pulse bilaterally. the remainder of her examination was unremarkable. disposition: discharged to home. discharge status: stable. discharge diagnosis: unstable angina status post off pump coronary artery bypass graft followed by redo coronary artery bypass graft on the night of surgery for v tach/v fibrillation arrest. follow up: includes seeing dr. in one month from the time of discharge. cardiologist will see her in two weeks and she will have follow up in the wound care clinic for wound check in one week from the time of discharge. , m.d. dictated by: medquist36 Procedure: Insertion of intercostal catheter for drainage Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries (Aorto)coronary bypass of one coronary artery Reopening of recent thoracotomy site Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Unspecified pleural effusion Hematoma complicating a procedure Cardiac arrest Other complications due to other cardiac device, implant, and graft Ventricular fibrillation Acute hepatitis C without mention of hepatic coma Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta