CHIEF COMPLAINT Coronary artery disease.

HISTORY OF PRESENT ILLNESS The patient is a 73-year-old patient of Dr. John Wayne and Dr. Kleinman in Megalopolis. The patient has had several angioplasties in the past. The patient had a cardiac catheterization in February 1997 and had a proximal left anterior descending stenosis of approximately 90% and distal circumflex stenosis of 80%. There was 70% diffuse irregularity of the right coronary artery. The patient had an angioplasty and stent placement of the proximal left anterior descending. She developed recurrent chest pain and underwent repeat cardiac catheterization. This study demonstrated recurrent stenosis, and the patient was recommended for bypass surgery.

PAST MEDICAL HISTORY The past medical history is significant for hypertension. She denies diabetes. She has chronic obstructive pulmonary disease, but has never smoked cigarettes.

CURRENT MEDICATIONS The patient's current medications include Procardia XL 60 mg daily, Zestril 20 mg daily, Cardura 4 mg daily, Proventil inhaler, Voltaren and aspirin.

REVIEW OF SYSTEMS The review of systems is negative for strokes and transient ischemic attacks.

ADMITTING PHYSICAL EXAMINATION

GENERAL The blood pressure is 170/88, pulse 80 and regular, and respirations 18. She weighs 240 pounds.

HEENT Examination of the head is normocephalic. The patient has bilateral carotid bruit. There is no jugular venous distention or lymphadenopathy.

LUNGS The lungs are clear to auscultation and percussion.

HEART Regular rate and rhythm without rub or gallop. There is a grade 2 systolic ejection murmur heard best in the aortic area without radiation.

ABDOMEN The abdomen is obese and nontender. The bowel sounds are active.

EXTREMITIES The extremities show no clubbing, cyanosis, or edema. Palpable pulses are present in the feet.

IMPRESSION Atherosclerotic cardiovascular disease status post multiple percutaneous transluminal coronary angioplasties with recurrent coronary artery disease.

PLAN The plan is for coronary artery bypass grafting. I have discussed with the patient in the preoperative period, the operative procedure, expected outcome, possible complications, including, but not limited to acute tubular necrosis, cerebrovascular accident, acute myocardial infarction, bleeding, infection, arrhythmia, pulmonary embolus, hepatitis and AIDS. The patient accepts the inherit risks with an estimated mortality of 3 to 4% and wishes to proceed.