Atherosclerosis of native arteries of the extremities with ulceration Ulcer of other part of foot Chronic airway obstruction not elsewhere classified Old myocardial infarction Personal history of tobacco use Diabetes mellitus without mention of complication type II or unspecified type not stated as uncontrolled Long-term (current) use of insulin Personal history of malignant neoplasm of bronchus and lung Personal history of malignant neoplasm of bladder
 
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: SURGERY
 
Allergies: 
Penicillins
 
Attending: ___.
 
Chief Complaint:
non-healing left foot ulcer
 
Major Surgical or Invasive Procedure:
Left poplitetal artery-Post Tib artery bypass
 
History of Present Illness:
This is a ___ man who presented with progressive left 
leg ischemia to the point of ulceration of the toes. He 
underwent arteriogram which showed occlusion of the posterior 
tibial artery and the tibioperoneal trunk and the anterior 
tibial artery. Given these findings the patient was consented 
for a popliteal to posterior tibial artery bypass in an attempt 
at limb salvage.

 
Past Medical History:
Lung CA
MI
Bladder CA
PAST SURGICAL HISTORY: R lung lobectomy ___ CABG*4 ___ TURT
bladder; L CEA

 
Social History:
___
Family History:
N/A
 
Physical Exam:
On discharge:
VS: T 98.2, HR 85, BP 135/55, RR 20, O2Sat 96%RA
Gen: NAD
CV: RRR, no m/r/g
Resp: CTAB
Abd: soft, nt/nd
Ext:      dp    pt
      R   dop   dop
      L   dop   dop
 
Pertinent Results:
___ 06:44PM BLOOD Hgb-11.3* Hct-33.3* Plt ___
___ 07:20AM BLOOD Hct-32.7* Plt ___
___ 06:44PM BLOOD ___ PTT-28.0 ___
___ 06:44PM BLOOD Glucose-108* UreaN-21* Creat-0.8 Na-142 
K-3.7 Cl-105 HCO3-32 AnGap-9
___ 03:08AM BLOOD UreaN-12 Creat-0.7 Na-139 K-4.1
___ 06:44PM BLOOD ALT-29 AST-51* AlkPhos-70
___ 04:05AM BLOOD ALT-26 AST-46* AlkPhos-70 TotBili-0.4
___ 06:44PM BLOOD Calcium-8.4 Phos-3.8 Mg-1.8
___ 04:05AM BLOOD Calcium-8.0* Phos-4.0 Mg-1.___, the patient was admitted direct to the holding room 
where patient was pre-oped, lined and consented. Patient is a 
difficult foley catherter placement, therefore it was decided 
that the patient will go to surgery without a foley catheter. 
Patient was taken to the OR for L ___ bypass. Patient 
tolerated the procedure well, recovered in the PACU then 
transferred to the VICU. Lower extremity bypass pathway started.

___, the patient's vital signs was stable. Patient has not 
voided since surgery, was allowed to sit at the edge of the bed 
to void. Patient was able to void and had been voiding since. 
Continued on pathway. Good pain control.

___, patient was stable coninuing on the distal bypass 
pathway. He got OOB to chair on POD 2 and walked with physical 
therapy on POD 3. He was cleared to go home by ___.

___, no events overnight. at the time of discharge, patient was 
afebrile with stable vital signs, tolerating a regular diet, 
ambulating and voiding without assistance, with his pain well 
controled.
 
Medications on Admission:
amlodipine 5 mg qd
metoprolol 50 mg qd
pregabalin 75 mg qd
duloxetine 60 mg qd
simvastatin 20 mg qhs
allopurinol ___ mg qd
percocet prn
ASA 325 mg qd
lantus 50 units SC QHS
 
Discharge Medications:
1. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) 
Capsule, Delayed Release(E.C.) PO DAILY (Daily).  
2. Pregabalin 75 mg Capsule Sig: One (1) Capsule PO DAILY 
(Daily).  
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  

4. Allopurinol ___ mg Tablet Sig: Three (3) Tablet PO DAILY 
(Daily).  
5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr 
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).  
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY 
(Daily).  
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 
times a day).  
9. Oxycodone 5 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) 
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
10. Insulin Glargine 100 unit/mL Solution Sig: Fifty (50) units 
Subcutaneous at bedtime.  
11. Santyl 250 unit/g Ointment Sig: One (1) application Topical 
once a day: apply topically to left ___ toe daily.
Disp:*1 tube* Refills:*0*

 
Discharge Disposition:
Home With Service
 
Facility:
___
 
___:
Non-healing left foot ulcer
History of:
lung ca 
MI
Bladder ca  
PSH: R lung lobectomy ___ CABG*4 ___ TURT bladder; L CEA; 
RLE angio ___  
 
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent

 
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Discharge Instructions
 
ACTIVITIES:
- ambulate essential distances ___ with Dr. ___
- ___ wrap leg from foot-knee when ambulating, to prevent 
swelling
- Your operated leg is expected to have some swelling and will 
resolve over time
- Elevate leg when sitting
- no driving till ___
- may shower, pat dry your incisions, no tub baths
 
WOUND:
- Keep wound dry and clean, call if noted to have redness, 
draining, swelling, or if temp is greater than ___
- Your staples will be removed on your ___ with Dr. ___
 
___:
- Diet as tolerated eat a well balanced meal 
- Your appetite will take time to normalize
- Prevent constipation by drinking adequate fluid and eat foods 
rich in fiber, take stool softener while on pain medications
 
MEDICATIONS:
- Continue all medications as directed 
- Take your pain medications conservatively
- Your pain will get better over time
 
___ APPOINTMENTS:
- Keep all ___ appointments
- Call Dr. ___ for ___ appointment. Phone 
___

 
Followup Instructions:
___

{'non-healing left foot ulcer': ['Atherosclerosis of native arteries of the extremities with ulceration', 'Ulcer of other part of foot'], 'progressive left leg ischemia': ['Atherosclerosis of native arteries of the extremities with ulceration'], 'lung CA': ['Personal history of malignant neoplasm of bronchus and lung'], 'MI': ['Old myocardial infarction'], 'Bladder CA': ['Personal history of malignant neoplasm of bladder']}