text:  Docusate sodium 100 mg p.o. b.i.d. Ursodiol 300 mg p.o. b.i.d. Ascorbic acid 500 mg p.o. q.d. Zinc sulfate 220 mg p.o. q.d. Lansoprazole oral solution 30 mg per gastric tube q.d. Caspofungin acetate 50 mg IV q.d.   day 23 of treatment and patient should remain on it indefinitely . Nephrocaps one cap p.o. q.d. If on dialysis  please take after dialysis treatment . Metoclopramide 5 mg p.o. b.i.d.   take 30 minutes before meals . Fluconazole 200 mg p.o. q.h.d. Patient should remain on this medication . Magnesium sulfate 2 gm in 100 ml of D5W IV as needed for repletion p.r.n. Miconazole powder 2 one application t.p. t.i.d. p.r.n. 12. Acetaminophen 325 mg to 650 mg p.o. q.four to six hours p.r.n. 13. Albuterol one to two puffs inhaled q. six hours p.r.n. 14. Bisacodyl 10 mg per rectum h.s. as needed p.r.n. 15. Hydralazine hydrochloride 10 mg IV q. six hours p.r.n. systolic blood pressure greater than 140 . 16. Vancomycin 1 gm IV as needed for vancomycin level less than 15 . This is day 23 of treatment for an approximate six week course . 17. Ceftazidime 1 gm IV q.h.d. after dialysis . 18. Alteplase for catheter clearance 2 mg IV once times one dose for indwelling PermCath . DISCHARGE DIAGNOSES  Status post aortic valve replacement and coronary artery bypass grafting times four . Status post sternal debridement . Status post skin graft to chest incision . Status post open jejunostomy tube placement   open left subclavian PermCath placement . Status post DDD pacer placement with external generator . Status post abdominal repair of wound dehiscence of jejunostomy site . Status post percutaneous tracheostomy . Status post acute renal failure . Status post myocardial infarction . Hypertension . Hypercholesterolemia . Asthma . Peptic ulcer disease status post gastrectomy 30 years ago . Colon cancer status post colectomy with XRT four years ago . Peripheral vascular disease with history of bilateral lower extremity claudication . COPD with asbestosis on chest CT scan . The patient is discharged on Thursday   12-31   to a rehabilitation facility   on postoperative day 93   in stable condition   from the cardiac surgery recovery unit . Perry G. Ozuna   M.D. 83 -390 Dictated By  Keith E. Shafer   M.D. MEDQUIST36 D  2015-12-31 1112 T  2015-12-31 1119 JOB  04648 Signed electronically by  DR. Kelsey MOORMAN on  FRI 2016-01-08