Abdominal aneurysm without mention of rupture Atherosclerosis of native arteries of the extremities with intermittent claudication
 
Name:  ___                Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: SURGERY
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
abdominal aortic aneurysm
 
Major Surgical or Invasive Procedure:
___: aortography and bilateral lower extremity angiography 

 
History of Present Illness:
This patient is a ___ gentleman, who presents with 
complaints of left thigh claudication.  It is noninvasive and 
demonstrates diffuse peripheral vascular disease suggestive of 
inflow disease on the left and more peripheral disease below the 
knee bilaterally.  He is presenting for a diagnostic, possible 
therapeutic angiography.

 
Past Medical History:
CAD, Carotid stenosis, HTN, CKD

 
Social History:
___
Family History:
non-contributory
 
Physical Exam:
On Discharge:
Vitals: T=98.5, HR=65, BP=150/85, RR=18, SaO2=100 on RA
Gen: NAD, AAOx3
Abd: soft, nontender, nondistended
Pulse Exam: monophasic pulses on the left with a biphasic DP on 
the righ
 
Pertinent Results:
___ 07:05AM BLOOD Creat-1.3* Na-137 K-4.2 Cl-102
___ 07:05AM BLOOD Hct-35.1*
 
Brief Hospital Course:
___ admitted for aortography and bilateral lower extremity 
angiography.  He tolerated the procedure well and was brought to 
the floor in stable condition.  There, his diet was resumed.  He 
was bedbound initially but out of bed the next morning.  He 
tolerated his diet and his pulse exam was unchanged from 
admission.  He was then seen by Anaesthesia for preoperative 
clearance for a planned EVAR given his findings on 
aortography/angiography.  After he met with Anaesthesia, he was 
discharged home in stable condition.  He will follow up with Dr. 
___ as an outpatient to schedule his elective procedure.
 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY 
2. Atorvastatin 40 mg PO DAILY 
3. cilostazol *NF* 100 mg Oral BID 
4. Furosemide 20 mg PO DAILY 
5. Lisinopril 10 mg PO DAILY 
6. Ascorbic Acid ___ mg PO DAILY 
7. Multivitamins 1 TAB PO DAILY 

 
Discharge Medications:
1. Aspirin 81 mg PO DAILY 
2. Atorvastatin 40 mg PO DAILY 
3. Ascorbic Acid ___ mg PO DAILY 
4. cilostazol *NF* 100 mg Oral BID 
5. Furosemide 20 mg PO DAILY 
6. Lisinopril 10 mg PO DAILY 
7. Multivitamins 1 TAB PO DAILY 

 
Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
status post bilateral lower extremity angiography, aortography

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 
Discharge Instructions:
You were admitted for your abdominal aortic aneurysm.  We 
performed an operative study to better understand the anatomy 
and found the aneurysm.  We also evaluated your legs bilaterally 
with angiography.  You were seen by anaesthesia today for 
preoperative clearance for an endovascular repair of your aortic 
aneurysm.  You tolerated the angiography well and are clear to 
return home today.
 
Followup Instructions:
___

{'abdominal aortic aneurysm': ['Abdominal aneurysm without mention of rupture'], 'left thigh claudication': ['Atherosclerosis of native arteries of the extremities with intermittent claudication'], 'noninvasive': [], 'diffuse peripheral vascular disease': ['Atherosclerosis of native arteries of the extremities with intermittent claudication'], 'inflow disease': ['Atherosclerosis of native arteries of the extremities with intermittent claudication'], 'more peripheral disease below the knee bilaterally': ['Atherosclerosis of native arteries of the extremities with intermittent claudication']}