allergies: patient recorded as having no known allergies to drugs attending: chief complaint: asymptomatic major surgical or invasive procedure: - cabgx5(lima->lad, svg->diag, om1, om2, rca) history of present illness: 53 year old man with cad who sustained an mi in . a cardiac catheterization revealed severe three vessel disease and stenting was performed to his circumflex artery. given the severity of his disease, the cardiac surgical service was consulted. he is now admitted for surgical revascualrization past medical history: cad: stemi with total occlusion of lcx s/p thrombectomy and placement bare-metal stent on ; 3vd hypercholesterolemia no htn ("usually low") renal stones 10 yrs ago last colonoscopy 1.5 yrs ago (@ : polyps, otherwise neg) left adrenal nodule rll pulmonary nodule ? c. diff colitis sleep apnea colon polyps social history: smokes ppd since age 15. drinks 6 beers 1 night/week. no drugs. works as chief probation officer family history: father died of mi at age 57; grandfather with in 50's. physical exam: 60 sr 16 112/66 72" 206 gen: nad heent: ncat, perrla, eomi, anicteric sclera neck: supple, no jvd lungs: cta heart: rrr, no m/r/g abd: benign ext: warm, well perfused, no c/c/e. + pulses throughout. no varicosities. neuro: nonfocal. no carotid bruits pertinent results: 07:15am blood wbc-7.8 rbc-3.42* hgb-11.1* hct-31.4* mcv-92 mch-32.3* mchc-35.2* rdw-13.0 plt ct-237# 07:15am blood plt ct-237# 07:15am blood glucose-103 urean-12 creat-0.8 na-141 k-4.2 cl-103 hco3-32 angap-10 - echo prebypass 1. no atrial septal defect is seen by 2d or color doppler. 2. regional left ventricular wall motion is normal. 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.the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. trace aortic regurgitation is seen. 6.the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. post bypass 1.patient is being av paced and receiving an infusion of phenylephrine. 2. biventricular systolic function is unchanged. 3. trace to mild mitral regurgitation present. 4. aorta intact post decannulation. brief hospital course: mr. was admitted to the on for surgical management of his coronary artery disease. he was taken directly to the operating room where he underwent coronary artery bypass grafting to five vessels. postoperatively he was taken to the intensive care unit for monitoring. by postoperative day one, mr. had awoke neurologically intact and was extubated. he was then transferred to the step down unit for further recovery. he was gently diuresed towards his preoperative weight. the physical therapy service was consulted for assistance with his postoperative strength and mobility. his plavix was resumed given his previous stent placement. an orthopedic consult was obtained for right shoulder and neck pain. radiographic studies were negative for any vertebral abnormalities. ibuprofen was started with some relief of his symptoms. he will have an mri as an outpatient and will follow-up with the orthopedic service as an outpatient. mr. continued to make steady progress and was discharged home on postoperative day five. he will follow-up with dr. , his cardiologist and his primary care physician as an outpatient. medications on admission: aspirin 325mg qd plavix 75mg qd atenolol 25mg qd lipitor 80mg qd lisinopril 20mg qd discharge medications: 1. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po q12h (every 12 hours) for 7 days. disp:*28 capsule, sustained release(s)* refills:*0* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 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. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 5. ibuprofen 600 mg tablet sig: one (1) tablet po q8h (every 8 hours) for 1 weeks. disp:*21 tablet(s)* refills:*0* 6. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 7. furosemide 40 mg tablet sig: one (1) tablet po bid (2 times a day) for 7 days. disp:*14 tablet(s)* refills:*0* 8. hydromorphone 2 mg tablet sig: 1-2 tablets po every 4-6 hours as needed. disp:*50 tablet(s)* refills:*0* 9. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily): please continue as directed by dr . disp:*30 tablet(s)* refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: coronary artery disease s/p cabg myocardial infarction s/p stent hypertension elevated cholesterol renal calculi discharge condition: good. discharge instructions: shower, no baths or swimming monitor wounds for infection - redness, drainage, or increased pain report any fever greater than 101 report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week no creams, lotions, powders, or ointments to incisions no driving for approximately one month no lifting more than 10 pounds for 10 weeks please call with any questions or concerns followup instructions: dr in 4 weeks () please call for appointment dr in 1 week () please call for appointment dr in weeks - please call for appointment orthopedics - dr () in 1 week after mri - please call for appointment mri shoulder with results to dr - please call to schedule wound check appointment 2 as instructed by nurse () Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of four or more coronary arteries Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Percutaneous transluminal coronary angioplasty status Unspecified sleep apnea Other diseases of lung, not elsewhere classified Calculus of kidney Subendocardial infarction, subsequent episode of care