text:  Brother with MI at age 35 Father with MI  CABG died at age 60 . Physical Exam Vitals  BP 144  90   HR 64   RR 14 General  well developed male in no acute distress HEENT  oropharynx benign   poor dental health Neck  supple   no JVD Heart  regular rate   normal s1s2   no murmur Lungs  clear bilaterally Abdomen  soft   nontender   normoactive bowel sounds Ext  warm   no edema   no varicosities Pulses  2 distally Neuro  nonfocal Pertinent Results 2014 -04-24 0730AM BLOOD Hct  25.9 2014-04-23 0705AM BLOOD WBC  5.9 RBC  2.72  Hgb  8.6  Hct  25.2  MCV  93 MCH  31.5 MCHC  34.0 RDW  13.0 Plt Ct  150 2014-04-23 0705AM BLOOD Plt Ct  150 2014-04-24 0730AM BLOOD UreaN  11 Creat  0.8 K  4.4 2014-04-21 ECHO No spontaneous echo contrast is seen in the body of the left atrium . No mass  thrombus is seen in the left atrium or left atrial appendage . No spontaneous echo contrast is seen in the body of the right atrium . A patent foramen ovale  secundum ASD is present . A left-to-right shunt across the interatrial septum is seen at rest . A right-to-left shunt across the interatrial septum is seen at rest with injection of agitated saline contrast . The inferior vena cava is dilated  >2.5 cm  . Left ventricular wall thickness   cavity size   and systolic function are normal  LVEF >55  . Left ventricular wall thicknesses are normal . Regional left ventricular wall motion is normal . Overall left ventricular systolic function is normal  LVEF>55  . Right ventricular chamber size and free wall motion are normal . The ascending   transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque . The aortic valve leaflets  3  appear structurally normal with good leaflet excursion and no aortic regurgitation . No aortic regurgitation is seen . The mitral valve appears structurally normal with trivial mitral regurgitation . The mitral valve leaflets are structurally normal . There is no pericardial effusion . POST BYPASS Flow across the interatrial septum is no longer visualized with color flow doppler or with injection of agitatated saline at rest or with valsalva . The study is otherwise unchanged from pre-bypass . 2014-04-22 CXR Previous right pneumothorax has resolved except for what is either a small fissural component or a bulla adjacent to the minor fissure . May be a small right pleural effusion . Right apical pleural tube in place . Left lung clear from basal atelectasis . Paratracheal mediastinal hematoma is resolving . Heart size is normal . Tip of the left internal jugular line projects over the SVC . Brief Hospital Course  Mr. Freeman was admitted to the Nantucket Cottage Hospital on 2014-04-21 for surgical management of his PFO . He was taken to the operating room where he underwent a mini-thoracotomy with closure of his patent foramen ovale  PFO  . Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring . Within a few hours   he woke neurologically intact and was extubated . Aspirin was resumed. On postoperative day one   he was transferred to the cardiac surgical step down unit . He was gently diuresed towards his preoperative weight . The physical therapy service was consulted for assistance with his postoperative strength and mobility . Iron and vitamin C were started for postoperative anemia . Mr. Freeman maintained stable hemodynamics with a normal sinus rhythm throughout his postoperative course . He continued to make steady progress and was discharged home on postoperative day three . He will follow-up with Dr. de la Cisneros   Dr. Belt   his cardiologist and his primary care physician as an outpatient . Medications on Admission  Plavix 75mg daily aspirin 81mg daily Discharge Medications  1. Potassium Chloride 10 mEq Capsule   Sustained Release Sig  Two  2  Capsule   Sustained Release PO Q12H  every 12 hours  for 5 days . Disp  10 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  2  4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig  1-2 Tablets PO every 4-6 hours as needed for pain . Disp  50 Tablet s  Refills  0  5. Ferrous Sulfate 325  65  mg Tablet Sig  One  1  Tablet PO DAILY  Daily   Take for one month then stop . Disp  30 Tablet s  Refills  0  6. Camphor-Menthol 0.5-0.5  Lotion Sig  One  1  Appl Topical TID  3 times a day  as needed . Disp  qs qs  Refills  0  7. Ascorbic Acid 500 mg Tablet Sig  One  1  Tablet PO BID  2 times a day   Take for one month then stop . Disp  60 Tablet s  Refills  0  8. Furosemide 20 mg Tablet Sig  One  1  Tablet PO BID  2 times a day  for 5 days . Disp  10 Tablet s   Refills  0  Discharge Disposition  Home with Service Discharge Diagnosis  PFO TIA lung nodule  followed by Dr. Belt  s  p fissurectomy  skull Fx Discharge Condition  Good Discharge Instructions  1 Shower   wash incisions with mild soap and water and pat dry . No lotions   creams or powders to incisions . Call with fever >101   redness or drainage from incision   or weight gain more than 2 pounds in one day or five pounds in one week . 3 No driving while on narcotics . Take lasix twice daily with potassium for five days then stop . Take Vitamin C with iron for one month then stop . Call with any questions or concerns . Followup Instructions Follow up with Dr. Heird in four weeks   671 745 2553 Follow up with Dr. Knowlton in 1-2 weeks   246 828-4417 Follow up with Dr. Eckman in 2-3 weeks   506 946-4576 Call all providers for appointments . CAT SCAN Phone  476 713 6117 Date  Time  2014-10-16 915 Edna Arnold   MD Phone  300 922-6590 Date  Time  2014-10-16 230 Melonson de la Donnelly MD 08-301 Completed by  Jeremy N. P. Moschella PA 80-BYE 2014-04-24  1103 Signed electronically by  DR. Dorothy au Pratt on  FRI 2014-06-06 1027 AM