Atherosclerosis of native arteries of the extremities with ulceration Ulcer of other part of foot Diabetes mellitus without mention of complication type II or unspecified type not stated as uncontrolled Unspecified essential hypertension Coronary atherosclerosis of unspecified type of vessel native or graft Aortocoronary bypass status Old myocardial infarction Personal history of tobacco use 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 big toe ulcer
 
Major Surgical or Invasive Procedure:
Diagnostic angiogram left lower extremity

 
History of Present Illness:
___ year old year old gentleman with h/o
trauma to Left big toe when he stubbed it. Was being treated 
with
antibiotics by his PCP. When it failed to heal he had 
noninvasive
arterial studies done whowed decreased blood supply to his left
leg. was seen by ___ was scheduled for an angiogram.

 
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:
Admission:
Neuro/Psych: Oriented x3, Affect Normal, NAD. 
Neck: No right carotid bruit, No left carotid bruit, abnormal: L
CEA scar. 
Skin: No atypical lesions. 
Heart: Regular rate and rhythm. 
Lungs: Clear, Normal respiratory effort. 
Gastrointestinal: Non distended, No masses. 
Rectal: Not Examined. 
Extremities: No popiteal aneurysm, No femoral bruit/thrill, No
RLE edema, No LLE Edema, No varicosities. 

 
Pertinent Results:
___ 06:20AM BLOOD Hct-37.9*
___ 06:20AM BLOOD UreaN-13 Creat-0.9 K-4.6

CHEST (PRE-OP PA & LAT) Study Date of ___ 7:51 ___ 
PA AND LATERAL VIEWS OF THE CHEST: The appearance of the right 
hemithorax is unchanged since ___, with an elevated right 
hemidiaphragm and overall volume loss consistent with prior 
resection. There is likely a small right pleural effusion, 
similar to prior exams. The left lung remains well expanded and 
clear without consolidation or left pleural effusion. The heart 
size is normal. There is no hilar or mediastinal enlargement. 
Pulmonary vascularity is normal.  
Median sternotomy wires and mediastinal clips are unchanged. 
Pleural 
calcifications consistent with asbestos exposure are again 
noted. 
IMPRESSION: No acute cardiopulmonary abnormalities. Stable 
volume loss of 
the right lung following resection.  

 
Brief Hospital Course:
___, patient was admitted for pre-op for left lower extremity 
angiogram. patient was started on IV broad spectrum antibiotics. 
Routine labs, ECG, CXR were done. Patient was pre-oped, 
consented, made NPO after MN, and IV hydrated. 

On ___, the patient was taken to the angio suite and 
underwent left lower extremity angiogram, patient was determined 
to need popliteal artery-posterior tibila artery bypass. This 
was booked for ___. Patient recovered, then 
transferred back to ___ 5. Patient was on bed rest for the 
prescribed amount of time. PO meds and diet resumed.

On ___, the patient's labs were within normal limits. The 
patient ambulated, eating and voiding. Vein mapping was done and 
seen by PAT in preparation for OR on ___. Discharged to 
home in good condition. He will return on ___ for a 
shceduled bypass surgery. Instructions were given for patient to 
call Dr. ___ for instructions regarding his 
surgery.
 
Medications on Admission:
Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  
Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 
times a day).  
Pregabalin 75 mg Capsule Sig: One (1) Capsule PO DAILY (Daily).  

Duloxetine 60 mg Capsule, Delayed Release(E.C.) PO DAILY 
(Daily).  
Simvastatin 20 mg Tablet Sig: Two (1) Tablet PO DAILY (Daily).  
Allopurinol ___ mg Tablet Sig: Three (1) Tablet PO DAILY 
(Daily).  
Oxycodone-Acetaminophen ___ mg Tablet Sig: One (1) Tablet PO 
Q6H (every 6 hours) as needed for pain.  
Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) 
Tablet, Delayed Release (E.___.) PO DAILY (Daily).  
Glargine Sig: Fifty (50) units subcutaneous once a day.  
Import Discharge Medications  
CoQ10 1 daily
multivitamin 1 daily
Glargine 50 units SC daily

 
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  

2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID 
(2 times a day).  
3. Pregabalin 75 mg Capsule Sig: One (1) Capsule PO DAILY 
(Daily).  
4. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) 
Capsule, Delayed Release(E.C.) PO DAILY (Daily).  
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY 
(Daily).  
6. Allopurinol ___ mg Tablet Sig: Three (3) Tablet PO DAILY 
(Daily).  
7. Oxycodone-Acetaminophen ___ mg Tablet Sig: One (1) Tablet 
PO Q6H (every 6 hours) as needed for pain.  
8. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) 
Tablet, Delayed Release (E.C.) PO DAILY (Daily).  
9. Glargine  Sig: Fifty (50) units subcutaneous  once a day.  

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Left lower extremity ischemia with ulceration
History of:
lung ca 
MI
Bladder ca
PSH: R lung lobectomy ___ CABG*4 ___ TURT bladder; L CEA  

 
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
Post Angiogram Angioplasty Discharge Instructions
 
- Monitor your groin, call if pain, swelling, and bruising is 
noted
 
- No lifting or straining
 
- Stool softener while on pain medications
 
- If bleeding is noted in the groin, hold pressure and go to the 
ED
 
- Resume normal activities gradually
 
- Continue all medications as instructed 
 

 
Followup Instructions:
___

{'Non healing left big toe ulcer': ['Atherosclerosis of native arteries of the extremities with ulceration', 'Ulcer of other part of foot'], 'Decreased blood supply to left leg': ['Atherosclerosis of native arteries of the extremities with ulceration'], 'History of trauma to Left big toe': [], 'Elevated right hemidiaphragm': [], 'Volume loss consistent with prior resection': [], 'Small right pleural effusion': [], 'Stable volume loss of the right lung following resection': [], 'Asbestos exposure': [], 'No acute cardiopulmonary abnormalities': []}