allergies: penicillins / motrin / bactrim / codeine attending: chief complaint: chest pain major surgical or invasive procedure: cardiac catheterization coronary artery bypass graft x2, left internal mammary artery to the left anterior descending artery, and saphenous vein graft to obtuse marginal; endoscopic harvesting of the long saphenous vein. history of present illness: 49 year old male who developed exertional angina and was sent for an outpatient persantine stress. during the stress test, he had chest pain with depression. imaging revealed a large severe anteroseptal/apical defect with an ef 35%. pt was transferred to the er and ultimately transferred for further cardiac workup at . dr. was consulted for coronary artery bypass grafting. past medical history: coronary artery disease insulin dependent diabetes mellitus asthma hypothyroidism hypertension hyperlipidemia depression vertigo diabetic neuropathy bilateral great toe ulcers left lateral malleolus ulcer ?h/o tia last year -on plavix h/o osgood schlatter h/o swallowing difficulty- s/p ?balloon to trachea (no stent) cartilage removed from left knee for osgood schlatter left inguinal hernia repair pilonidal cyst x2 tonsillectomy social history: lives with: friend- rents a room occupation: disabled (s/p accident at work and depression)- worked for 22yrs. at grocery store tobacco: current smoker- 1-2cigs/day (some days none) etoh: rare family history: brother had heart surgery mom died 53 " problem" dad died 55 mi grandmother with cabg in her 70s physical exam: vs: t=98.8 bp=127/75 hr= 88 rr=20 o2sat=96% on ra general: wdwn m in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of 6 cm. cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, scars, or xanthomas. purulent diabetic ulcer 2 inches in diameter on right great toe and 2cm ulcer on left lateral mallelous both of which are foul smelling. pulses: right: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ left: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ pertinent results: 06:05am blood wbc-8.6 rbc-3.32* hgb-9.6* hct-27.6* mcv-83 mch-28.9 mchc-34.8 rdw-14.2 plt ct-332# 09:51pm blood wbc-6.2 rbc-4.11* hgb-11.8* hct-32.8* mcv-80* mch-28.6 mchc-35.8* rdw-13.3 plt ct-282 03:05pm blood neuts-81.1* lymphs-15.2* monos-2.3 eos-0.9 baso-0.4 09:00am blood neuts-50.2 lymphs-42.1* monos-5.0 eos-2.5 baso-0.3 06:05am blood plt ct-332# 04:29pm blood pt-14.1* ptt-25.1 inr(pt)-1.2* 09:51pm blood plt ct-282 09:51pm blood pt-12.5 ptt-22.6 inr(pt)-1.1 06:05am blood glucose-77 urean-15 creat-0.8 na-136 k-4.8 cl-99 hco3-28 angap-14 09:51pm blood glucose-248* urean-13 creat-1.1 na-136 k-4.2 cl-101 hco3-26 angap-13 09:07am blood ck(cpk)-445* 09:00am blood alt-8 ast-11 alkphos-63 amylase-42 totbili-0.3 dirbili-0.1 indbili-0.2 09:46pm blood ck-mb-3 ctropnt-0.08* 06:05am blood mg-1.8 03:19am blood calcium-7.5* phos-3.1# mg-2.0 09:00am blood vitb12-259 09:00am blood %hba1c-10.2* eag-246* pa and lateral chest. history: 49-year-old male with cabg. evaluate for interval change. findings: comparison is made to previous study from . there is a right ij central venous catheter with distal lead tip at the cavoatrial junction. there are areas of plate-like atelectasis at both lung bases, which are relatively stable. there is no overt pulmonary edema. there is a small right-sided pleural effusion. dr. approved: sun 10:23 am echocardiographic measurements results measurements normal range left ventricle - ejection fraction: 45% >= 55% left ventricle - lateral peak e': 0.10 m/s > 0.08 m/s left ventricle - septal peak e': *0.08 m/s > 0.08 m/s left ventricle - ratio e/e': 11 < 15 aortic valve - peak velocity: 1.1 m/sec <= 2.0 m/sec mitral valve - e wave: 1.0 m/sec mitral valve - a wave: 1.0 m/sec mitral valve - e/a ratio: 1.00 mitral valve - e wave deceleration time: 189 ms 140-250 ms findings left ventricle: normal lv wall thickness. normal lv cavity size. mildly depressed lvef. right ventricle: rv not well seen. aortic valve: normal aortic valve leaflets (3). no as. no ar. mitral valve: normal mitral valve leaflets with trivial mr. no mvp. normal mitral valve supporting structures. tricuspid valve: normal tricuspid valve leaflets with trivial tr. normal tricuspid valve supporting structures. no ts. pericardium: no pericardial effusion. general comments: suboptimal image quality - bandages, defibrillator pads or electrodes. regional left ventricular wall motion: n = normal, h = hypokinetic, a = akinetic, d = dyskinetic conclusions left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is mildly depressed (lvef= 45 %) secondary to akinesis of the apical third of the interventricular septum and hypokinesis of the apex. 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 mitral valve prolapse. there is no pericardial effusion. compared to previous study of , the left ventricular ejection fraction is increased. electronically signed by , md, interpreting physician 14:07 brief hospital course: admitted for cardiac evaluation and underwent cardiac catheterization which revealed coronary artery disease. cardiac surgery was consulted and he underwent preoperative workup. he remained in the hospital due to chest pain with ambulation and was brought to the operating room on for coronary artery bypass graft surgery. see operative report for further details. he tolerated the procedure well and was transferred to intensive care unit for management. he awoke neurologically intact and was extubated postoperatively without difficulty. physical therapy worked with him on strength and mobility. he continued to progress, was consulted for diabetes management due to hgba1c of 10 preoperatively. his insulin was adjusted and he was ready for discharge home with services on post operative day 6. medications on admission: atenolol 25mg daily lantus 35units naproxen prn asa 325mg daily plavix 75mg simvastatin 40mg daily albuterol mdi lasix 20mg daily antivert 12.5mg q8hr prn levoxyl 150mcg daily gabapentin 100mg qhs cipro 500mg gentamicin topical ointment to foot ulcers discharge medications: 1. levothyroxine 150 mcg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 2. gabapentin 100 mg capsule sig: one (1) capsule po hs (at bedtime). disp:*30 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. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 5. simvastatin 80 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 6. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily) as needed for prev cva. disp:*30 tablet(s)* refills:*0* 7. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 8. metoprolol succinate 100 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). disp:*30 tablet sustained release 24 hr(s)* refills:*0* 9. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*60 tablet(s)* refills:*0* 10. furosemide 40 mg tablet sig: one (1) tablet po daily (daily) for 7 days. disp:*7 tablet(s)* refills:*0* 11. potassium chloride 10 meq capsule, sustained release sig: one (1) capsule, sustained release po once a day for 7 days. disp:*7 capsule, sustained release(s)* refills:*0* 12. lantus 100 unit/ml solution sig: sixty (60) units subcutaneous once a day: please take at dinner on and then take at bedtime and continue to take at bedtime . disp:*qs qs* refills:*2* 13. humalog 100 unit/ml solution sig: per sliding scale subcutaneous before meals and bedtime : follow sliding scale minimum dose in day 8 units up to maximum of 77 units total for all 4 doses . disp:*qs qs* refills:*0* 14. diabetes supplies test strips for glucometer 15. sliding scale insulin insulin sc sliding scale breakfast lunch dinner bedtime humalog humalog humalog humalog glucose insulin dose insulin dose insulin dose insulin dose 0-70 mg/dl proceed with hypoglycemia protocol proceed with hypoglycemia protocol proceed with hypoglycemia protocol proceed with hypoglycemia protocol 71-100 mg/dl 8 units 8 units 8 units 0 units 101-150 mg/dl 11 units 11 units 11 units 0 units 151-200 mg/dl 13 units 13 units 13 units 0 units 201-250 mg/dl 15 units 15 units 15 units 8 units 251-300 mg/dl 17 units 17 units 17 units 10 units 301-350 mg/dl 19 units 19 units 19 units 12 units 351-400 mg/dl 21 units 21 units 21 units 14 units discharge disposition: home with service facility: vna, discharge diagnosis: coronary artery disease s/p cabg diabetes mellitus hypertension hyperlipidemia asthma discharge condition: alert and oriented x3 nonfocal ambulating with steady gait sternal pain controlled with dilaudid prn discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month until follow up with surgeon no lifting more than 10 pounds for 10 weeks please call with any questions or concerns followup instructions: surgeon dr. # appointment arranged for , at 1pm please call to schedule appointments primary care dr in weeks cardiologist dr in weeks md Procedure: Venous catheterization, not elsewhere classified Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Left heart cardiac catheterization (Aorto)coronary bypass of one coronary artery Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Congestive heart failure, unspecified Unspecified essential hypertension Unspecified acquired hypothyroidism Asthma, unspecified type, unspecified Polyneuropathy in diabetes Ulcer of other part of foot Long-term (current) use of insulin Family history of ischemic heart disease Acute systolic heart failure Chronic total occlusion of coronary artery Diabetes with neurological manifestations, type II or unspecified type, uncontrolled