Abdominal aneurysm without mention of rupture Coronary atherosclerosis of native coronary artery Postprocedural fever Osteoarthrosis unspecified whether generalized or localized pelvic region and thigh Hypertensive chronic kidney disease unspecified with chronic kidney disease stage I through stage IV or unspecified Chronic kidney disease unspecified Other specified forms of chronic ischemic heart disease Peripheral vascular disease unspecified Inguinal hernia without mention of obstruction or gangrene unilateral or unspecified (not specified as recurrent)
 
Name:  ___                Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: SURGERY
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
left groin pain 
 
Major Surgical or Invasive Procedure:
___ ENDOVASCULAR AORTIC ANEURYSM REPAIR  
 
History of Present Illness:
___ presents for repair of abdominal aortic aneurysm.  The 
aneurysm was discovered ___ on angiogram when the patient 
presented for left thigh claudication.  At that time the 
aneurysm was approximately 6.5cm; the patient was scheduled for 
EVAR.  
 
Past Medical History:
Past Medical History:  6cm AAA, bilateral CIA aneurysms, PVD 
with
LLE claudication, bilateral CFA, SFA, and profunda disease, CAD,
Carotid stenosis, HTN, CKD, SCC R ear

Past Surgical History:  ___: aortography and bilateral lower
extremity angiography

 
Social History:
___
Family History:
non-contributory
 
Physical Exam:
Vitals: afebrile, vital signs stable
Gen: well appering, no apparent distress
Abd: soft, nontender, nondistended
Cardio: regular rate and rhythm
Pulm: clear to ascultation bilaterally, nonlabored breathing
Ext: b/l groin puncture sites intact with dermabond, no bleeding 
or hematoma, mild tenderness to palpation; left leg pain with 
external rotation and abduction 
 
Pertinent Results:
HIP UNILAT MIN 2 VIEWS LEFT     ___  
IMPRESSION:  Severe degenerative changes involving the left hip.

CHEST (PORTABLE AP)   ___ 
FINDINGS:  Lung volumes are relatively low.  There is a status 
post CABG with sternal wires in situ.  Normal size of the 
cardiac silhouette, tortuosity of the thoracic aorta.  Areas of 
mild atelectasis are seen at both lung bases.  No evidence of 
pneumonia and no pulmonary edema.  No pneumothorax. 

 
Brief Hospital Course:
The patient was admitted to the Vascular Surgery service.  He 
had a known 7cm aneurysm (previously scheduled for elective 
EVAR) as well as a left inguinal hernia but presented with left 
hip/groin pain.  Workup was negative for rupture or growth of 
the aneurysm and the inguinal hernia was nonincarcerated without 
any obstruction.  However, the patient was taken for 
endovascular aortic aneurysm repair on ___ (see operative 
note for further details).  The procedure went well without any 
complications.  
.
Postoperatively, the patient had a fever to 101.7F but workup 
was negative and the patient was subsequently afebrile.  The 
patient continued to have left hip pain and radiograph of the 
hip showed severe degenerative osteoarthritis.  Orthopaedics was 
consulted; they recommended physical therapy and outpatient 
Orthopaedics follow up; if the patient continues to be unable to 
bear weight on the left leg an MRI may be indicated to rule out 
occult hip fracture.  Secondary to the patient's poor mobility, 
he was discharged to Rehab for further physical therapy.  

 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO DAILY 
2. Furosemide 20 mg PO DAILY 
3. Lisinopril 10 mg PO DAILY 
4. Aspirin 81 mg PO DAILY 
5. Ascorbic Acid ___ mg PO DAILY 
6. cilostazol *NF* 100 mg Oral BID 
7. Multivitamins 1 TAB PO DAILY 

 
Discharge Medications:
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. Acetaminophen 650 mg PO Q6H:PRN fever/pain 
7. Docusate Sodium 100 mg PO BID 
8. OxycoDONE (Immediate Release)  ___ mg PO Q4H:PRN pain 
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation 
10. Senna 1 TAB PO BID:PRN constipation 
11. Ascorbic Acid ___ mg PO DAILY 
12. Multivitamins 1 TAB PO DAILY 

 
Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
AAA
L. Hip DJD
 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (___ 
or cane).
 
Discharge Instructions:
MEDICATIONS:
Take Aspirin 81mg (enteric coated) once daily 
Do not stop Aspirin unless your Vascular Surgeon instructs you 
to do so. 
Continue all other medications you were taking before surgery, 
unless otherwise directed
You make take Tylenol or prescribed pain medications for any 
post procedure pain or discomfort

WHAT TO EXPECT AT HOME:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart (use ___ 
pillows or a recliner) every ___ hours throughout the day and at 
night
Avoid prolonged periods of standing or sitting without your 
legs elevated
It is normal to feel tired and have a decreased appetite, your 
appetite will return with time 
Drink plenty of fluids and eat small frequent meals
It is important to eat nutritious food options (high fiber, 
lean meats, vegetables/fruits, low fat, low cholesterol) to 
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool 
softener while taking pain medication

ACTIVITIES:
When you go home, you may walk and go up and down stairs
You may shower (let the soapy water run over groin incision, 
rinse and pat dry)
Your incision may be left uncovered, unless you have small 
amounts of drainage from the wound, then place a dry dressing or 
band aid over the area that is draining, as needed
No heavy lifting, pushing or pulling (greater than 5 lbs) for 
1 week (to allow groin puncture to heal)
After 1 week, you may resume sexual activity
After 1 week, gradually increase your activities and distance 
walked as you can tolerate
No driving until you are no longer taking pain medications

CALL THE OFFICE FOR: ___
Numbness, coldness or pain in lower extremities 
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or 
green drainage from incisions
Bleeding from groin puncture site

FOR SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or 
incision)
Lie down, keep leg straight and have someone apply firm 
pressure to area for 10 minutes. If bleeding stops, call 
vascular office. If bleeding does not stop, call ___ for 
transfer to closest Emergency Room. 

 
Followup Instructions:
___

{'left groin pain': ['Abdominal aneurysm without mention of rupture', 'Peripheral vascular disease'], 'fever': ['Postprocedural fever'], 'severe degenerative changes involving the left hip': ['Osteoarthrosis'], 'left leg pain': ['Peripheral vascular disease'], 'mild tenderness to palpation': ['Abdominal aneurysm without mention of rupture', 'Inguinal hernia']}