Patient Details
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Medications |
Aspirin 100mg mane Clopidogrel 75mg mane Metoprolol 25mg BD Atorvastatin 40mg nocte Ramipril 10mg daily Pantoprazole 40mg mane Paracetamol 1g PO QID Targin 20/10mg PO BD Endone 10-20mg PO Q4H PRN Ondansetron 4-8mg IV Q4H PRN Clexane 40mg nocte |
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HPC |
Mr Hughes is now two days post his coronary artery bypass graft. He required a median sternotomy and a triple vessel bypass graft from his left great saphenous vein. There were no intraoperative complications associated with the procedure. His recovery has been uneventful to date. He has normal post sternotomy pain and requires a rolled-up towel to assist with deep breathing and coughing. He has required 2L of O2 via nasal prongs since the procedure and has not been mobilising as much as the team would like. This morning he developed a productive cough and had recently described subjective fevers. He is opening his bowels, passing urine with no dysuria, sternotomy and left leg graft site wound look healthy. The nursing staff have asked you to see this patient due to a fever of 38.5 degrees. |
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PSxHx |
Percutaneous coronary intervention with failed stenting Laparoscopic cholecystectomy |
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PMHx |
Hypertension Dyslipidaemia Ischaemic Heart Disease GORD Osteoarthritis |
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Allergies |
NKDA |
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FHx |
Mr Hughes’ father died of a heart attack at the age of 59. His mother is still alive at 91 years of age and lives in a low-level nursing home. She has no significant medical issues. Mr Hughes is the eldest of four siblings; one also suffers from ischaemic heart disease. |
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SHx |
Mr Hughes is a retired butcher from Port Stephens who lives at home with his wife. They are both independent in all their ADLs. Mr Hughes drinks only occasional alcohol but he does smoke. He has a 50 pack year smoking history, smoking a pack a day since he was 18 years old. |