CHIEF COMPLAINT: Ischemic right lower extremity

PRESENT ILLNESS: 66 M w/ PVD with rest pain s/p Right [**Name (NI) 1793**] PTA/stent
([**8-5**])-failed.  Presented to [**Hospital **] Hosp for urgent R CFA
endarterectomy w/ bovine pericardial patch angioplasty without
improvement in flow.  This was followed by a Right BK [**Doctor Last Name **]
endarterectomy and [**Location (un) **] patch and Right proximal CFA to BK [**Doctor Last Name **]
6mm PTFE ([**8-23**]).  There was no improvement in rest pain and
patient was transferred to the [**Hospital1 18**] for angiogram and possible
bypass with arm vein.

MEDICAL HISTORY: 1. PVD s/p:
     -Right [**Name (NI) 1793**] PTA/stent ([**8-5**])
     -R CFA endarterectomy w/ bovine pericardial patch

MEDICATION ON ADMISSION: Plavix 75', ASA 81', atenolol 50', lisinopril 5', zocor 80',
MTV, folate, fish oil

ALLERGIES: Percocet

PHYSICAL EXAM: VSS
Gen: NAD, A&OX3
Cardiac: RRR
Lungs: CTA
ABD: soft, non tender
RLE wound: mild erythema, mild swelling, staple line intact
Pulses: B/L fem palp, B/L DP/PT dop

FAMILY HISTORY: N/C

SOCIAL HISTORY: Retired carpenter, 50 pack year smoker, currently smoking, 6-8
beers per day.  Married, lives at home
Other complications due to other vascular device, implant, and graft,Blood in stool,Other postoperative infection,Cellulitis and abscess of leg, except foot,Acute posthemorrhagic anemia,Alcohol withdrawal,Delirium due to conditions classified elsewhere,Chronic total occlusion of artery of the extremities,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Other respiratory abnormalities,Benign neoplasm of rectum and anal canal,Internal hemorrhoids without mention of complication,Diverticulosis of colon (without mention of hemorrhage),Fall from other slipping, tripping, or stumbling,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Benign essential hypertension,Other and unspecified hyperlipidemia,Tobacco use disorder,Hip joint replacement,Other and unspecified alcohol dependence, unspecified,Other iatrogenic hypotension
Comp-oth vasc dev/graft,Blood in stool,Other postop infection,Cellulitis of leg,Ac posthemorrhag anemia,Alcohol withdrawal,Delirium d/t other cond,Chr tot occl art extrem,Gstr/ddnts NOS w/o hmrhg,Respiratory abnorm NEC,Benign neopl rectum/anus,Int hemorrhoid w/o compl,Dvrtclo colon w/o hmrhg,Fall from slipping NEC,Other staphylococcus,Abn react-anastom/graft,Benign hypertension,Hyperlipidemia NEC/NOS,Tobacco use disorder,Joint replaced hip,Alcoh dep NEC/NOS-unspec,Iatrogenc hypotnsion NEC
Admission Date:  [**2182-8-24**]              Discharge Date:   [**2182-9-11**]

Date of Birth:  [**2116-3-30**]             Sex:   M

Service: SURGERY

Allergies:
Percocet

Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Ischemic right lower extremity

Major Surgical or Invasive Procedure:
[**2182-8-24**] OPERATION PERFORMED.:
1. Right common femoral to anterior tibial artery bypass
    with non-reversed greater saphenous vein.
2. Angioscopy and valve lysis.
3. Ultrasound-guided puncture of left common femoral
    artery.
4. Contralateral second-order catheterization of right
    common femoral artery.
5. Abdominal aortogram.
6. Serial arteriogram of the right lower extremity.


History of Present Illness:
66 M w/ PVD with rest pain s/p Right [**Name (NI) 1793**] PTA/stent
([**8-5**])-failed.  Presented to [**Hospital **] Hosp for urgent R CFA
endarterectomy w/ bovine pericardial patch angioplasty without
improvement in flow.  This was followed by a Right BK [**Doctor Last Name **]
endarterectomy and [**Location (un) **] patch and Right proximal CFA to BK [**Doctor Last Name **]
6mm PTFE ([**8-23**]).  There was no improvement in rest pain and
patient was transferred to the [**Hospital1 18**] for angiogram and possible
bypass with arm vein.

Pt c/o pain in right lateral calf, worsening.  Has parasthesias
chronically bilateral.  Denies nausea, vomiting, CP/SOB.


Past Medical History:
1. PVD s/p:
     -Right [**Name (NI) 1793**] PTA/stent ([**8-5**])
     -R CFA endarterectomy w/ bovine pericardial patch

       angioplasty Right BK [**Doctor Last Name **] endarterectomy and [**Location (un) **] patch
       and Right proximal CFA to BK [**Doctor Last Name **] 6mm PTFE ([**8-23**])
2. HTN
3. Lipids
4. Hemachromatosis


Social History:
Retired carpenter, 50 pack year smoker, currently smoking, 6-8
beers per day.  Married, lives at home

Family History:
N/C

Physical Exam:
VSS
Gen: NAD, A&OX3
Cardiac: RRR
Lungs: CTA
ABD: soft, non tender
RLE wound: mild erythema, mild swelling, staple line intact
Pulses: B/L fem palp, B/L DP/PT dop

Pertinent Results:
[**2182-9-6**] 03:08AM BLOOD WBC-10.7 RBC-3.85* Hgb-12.1* Hct-34.0*
MCV-88 MCH-31.5 MCHC-35.7* RDW-16.5* Plt Ct-384
[**2182-9-5**] 04:00AM BLOOD WBC-12.8* RBC-3.83* Hgb-12.0* Hct-33.9*
MCV-89 MCH-31.3 MCHC-35.4* RDW-16.4* Plt Ct-319
[**2182-9-6**] 03:08AM BLOOD Plt Ct-384
[**2182-9-6**] 10:31PM BLOOD Glucose-134* UreaN-21* Creat-0.9 Na-137
K-4.2 Cl-106 HCO3-24 AnGap-11
[**2182-9-5**] 04:00AM BLOOD ALT-26 AST-26 LD(LDH)-239 AlkPhos-82
Amylase-180* TotBili-0.5
[**2182-9-4**] 05:10AM BLOOD Lipase-549*
[**2182-9-6**] 10:31PM BLOOD Calcium-8.1* Phos-3.5 Mg-2.0

Date: [**2182-9-6**]
Signed by [**First Name8 (NamePattern2) 2620**] [**Last Name (NamePattern1) 2621**], CCC-SLP on [**2182-9-6**] at 8:50 am
Affiliation: [**Hospital1 18**]

BEDSIDE SWALLOWING EVALUATION:

HISTORY:
Thank you for consulting on this 66 y/o male with right sided
[**Name (NI) 1793**]
PTA / stent [**8-5**] that failed admitted on [**2182-8-24**] from OSH
following urgent right CFA enterectomy with bovine pericardial
patch angioplasty without improvement in flow. Pt had right BK
[**Doctor Last Name **] enterectomy  and [**Location (un) **] patch and right proximal CFA to BK
[**Doctor Last Name **] [**8-23**]. There was no improvement in rest pain and pt was
transferred to [**Hospital1 18**] for angioplasty and possible bypass with
arm
vein. Pt had continued critical limb ischemia and possible calf
tissue loss and is now s/p right SVG fem-BK [**Doctor Last Name **] graft [**8-24**].
Course has been complicated by DVTs and GI bleed.

Pt has been transferred to the VICU and was advanced to a full
liquid diet. We were consulted to evaluate for oral and
pharyngeal dysphagia. RN reported he has been tolerating well
and
pt denied coughing with meals. He has more concern regarding his
voice and feels he can't increase his volume.

EVALUATION:
The examination was performed while the patient was seated
upright in the chair in the VICU.

Cognition, language, speech, voice:
Pt was awake, alert and oriented x 3 with fluent language.
Speech
was mildly dysarthric. Voice was clear but with reduced volume.
He had difficulty increasing volume with cuing. Pt was able to
follow all basic commands.

Teeth: fair condition - several missing and or cracked
Secretions: wfl in the oral cavity, but intermittent wet vocal
quality

ORAL MOTOR EXAM:
symmetrical facial appearance with adequate lip seal and buccal
tone. Tongue was at midline with functional strength and ROM.

SWALLOWING ASSESSMENT:
Mr. [**Known lastname 65140**] was seen during breakfast with thin liquids (sup,
straw), purees and crackers. Mastication was timely and without
oral cavity residue. He did not have any overt coughing, throat
clearing or changes in vocal quality and denied the sensation of
aspiration or pharyngeal residue. O2 SATs remained stable.
Laryngeal elevation felt timely and wfl to palpation.

SUMMARY / IMPRESSION:
Mr. [**Known lastname 65140**] did not have any overt signs of aspiration and can be
advanced to thin liquids and regular consistency solids once
cleared medically. His voice is somewhat concerning,
particularly
given his prolonged intubation and while I feel he is achieving
adequate closure to prevent aspiration, he may not be achieving
complete adduction. He would likely benefit from an ENT
evaluation to assess vocal cord movement and continued speech
therapy services in rehab.

This swallowing pattern correlates to a Dysphagia Outcome
Severity Scale (DOSS) rating of 6, wfl with modified
independence.

RECOMMENDATIONS:
1. Suggest a PO diet of thin liquids and regular consistency
solids once cleared medically.

2. Pills whole with water.

3. ENT evaluation if possible before d/c and then continued
speech therapy services at rehab.

These recommendations were shared with the patient, nurse and
medical team.

____________________________________
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.S., CCC-SLP
Pager #[**Numeric Identifier 2622**]

Face time: 8:20-8:40
Total time:   50 minutes
_______________________________________________________________

OPERATIVE REPORT

[**Last Name (LF) **],[**First Name3 (LF) **] L.
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) **] on WED [**2182-8-28**]
4:54 PM

Name:  [**Known lastname **], [**Known firstname **]               Unit No:  [**Numeric Identifier 82933**]

Service:                          Date: [**2182-8-24**]

Date of Birth:  [**2116-3-30**]        Sex:  M

Surgeon:  [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 21890**]

PREOPERATIVE DIAGNOSIS:  Acute limb threat of right lower
extremity.

POSTOPERATIVE DIAGNOSES:  Acute limb threat of right lower
extremity.

OPERATION PERFORMED.:
1. Right common femoral to anterior tibial artery bypass
    with non-reversed greater saphenous vein.
2. Angioscopy and valve lysis.
3. Ultrasound-guided puncture of left common femoral
    artery.
4. Contralateral second-order catheterization of right
    common femoral artery.
5. Abdominal aortogram.
6. Serial arteriogram of the right lower extremity.

ASSISTANT:  [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3636**], M.D.

TOTAL FLUOROSCOPY TIME:  2.9 minutes.

CONTRAST:  36 ml of Visipaque.

TOTAL FLUIDS:  2 liters.

ESTIMATED BLOOD LOSS:  200.

SPECIMEN:  None.

FINDINGS:  Single-vessel runoff into the foot via the
anterior tibial which then perfuses the peroneal artery.
There was an adequate sized greater saphenous vein which was
used to perform the bypass graft in a non-reversed fashion.

DRAINS:  None.

COMPLICATIONS:  None.

CONDITION:  Guarded.

PATIENT ID:  This is a 66-year-old man who had previously had
rest pain of the right foot. He had previously undergone a
right femoral patch angioplasty and subsequently right
femoral to below-knee popliteal pro patent bypass graft. He
presents with continued rest pain and evidence of limb threat
with sensory loss in the right foot. Given these findings,
the patient was consented for a arteriogram, possible bypass
graft nerve to achieve limb salvage.

PROCEDURE IN DETAIL:  After informed consent was obtained,
the patient was brought to the operating room placed supine
on the operating room  table. General endotracheal anesthesia
was started. Vancomycin and gentamicin was given
intravenously prior to skin incision. The right leg, both
groins, and left upper extremity was prepped and draped in
usual sterile fashion. Using the ultrasound, the left common
femoral artery was  identified. It was patent. Previously
performed femoral to popliteal bypass graft on the left was
seen and puncture was made above the anastomosis of bypass
graft micro sheath. Hard copy images were stored in the
patient's chart for documentation purposes. Micro sheath was
used to access the left external iliac artery and followed by
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7648**] wire in abdominal aorta and a 4-French short sheath
in the left external iliac artery and Omni Flush catheter in
abdominal aorta.

Abdominal aortogram was performed. Contralateral second-order
catheterization of the right external iliac artery was
achieved with a combination of angled Glidewire and Omni
Flush catheters.  Serial arteriogram was then performed to
the right lower extremity. Based on the diagnostic findings,
the decision was made to intervene.  We had elected to
proceed with a femoral to contra tibial artery bypass graft.
We cut down the course of the greater saphenous vein.
Dissection was carried down using electrocautery and
saphenous vein was identified by sharp dissection. Dissection
of the greater saphenous vein continued all the way to the
saphenofemoral junction and distally into the mid calf. The
entire length of saphenous vein appeared to be quite usable
and appeared quite healthy. Previously seen tunnel pro patent
was  graft is seen. It had no pulse in it and is consistent
with our finding of a firm post bypass pro patent graft. Com
mon femoral artery was identified, dissected from surrounding
structures using sharp dissection. Vessel loops were used to
control the common femoral artery, the superficial femoral,
the profunda femoris artery, and the circumflex femoral
vessels.

Next, exploration of the proximal anterior tibial artery was
achieved via a longitudinal skin incision the lateral aspect
of the leg. Dissection was carried down using electrocautery
and the anterior tibial artery is identified and all side
branches of the anterior tibial artery were carefully
controlled with 2-0 silk ties and proximal and distal control
was controlled with vessel loops on the anterior tibial
artery. The anterior tibial artery appeared quite soft at
this level, although there was some atherosclerosis within
the walls. Once we had proximal distal control in our inflow
and outflow vessels, heparin 6000 units was given
intravenously to maintain activated clotting time for 20-50
seconds throughout the entire case. Vessel control was
achieved via pulling up on the vessel loops and the
previously-placed pro patent graft was disattached from the
common femoral artery. This left a perfect hole on the bovine
pericardial patch that was previously placed. A subcutaneous
tunnel was created in the lateral aspect of the leg and the
greater saphenous vein was harvested via ligating side
branches between 4-0 silk ties. The distal greater saphenous
vein was ligated with 2-0 silk tie and the proximal saphenous
vein at its junction with the saphenofemoral was ligated with
3-0 Vicryl suture. Saphenous vein was removed and an
angioscopy with valve lysis was performed with a [**Doctor Last Name 4048**]
valvulotome.  All valves were cut under endoscopic
visualization and with good flow throughout the entire lumen.
Saphenous vein was passed through the subcutaneous tunnel
created to the lateral aspect of the leg and care was taken
to ensure that the graft lay the without kinking or twisting.
A end-to-side anastomosis of the greater saphenous vein graft
to the common femoral artery was achieved with a two running
sutures of 5-0 Prolene. There was excellent hemostasis at the
anastomosis. Proximal and distal clamps were released and
flushing of the graft was performed. There was excellent
pulsatile flow within the distal end of the graft.  The graft
was matched to the anterior tibial artery in end-to-side
anastomosis of a spatulated vein and the longitudinal
anterior tibial arteriotomy was performed with two running 6-
0 Prolene sutures. Backflushing and fore flushing of four
vessels were performed prior to completion of the
anastomosis. There appeared to be a flap of tissue within the
anterior tibial artery proximally that was retrieved. A 1.5
mm coronary dilator was passed distally into the anterior
tibial artery which allowed good backbleeding from the
anterior tibial artery. Anastomosis completed, Doppler exam
of the flow vessel showed excellent signal within the vessel
and we were happy with our results. Therefore, hemostasis
achieved at all wounds and  the wall incisions in the groin
was closed in three layers with 2-0 Vicryl and staples
distally within the medial incision. The wound was closed
with 2-0 Vicryl in a single deep layer and a 4-0 Monocryl for
the skin and Dermabond for the skin. Lateral incision was
closed with 4-0 Vicryl and Dermabond for the skin. Sterile
dressing was applied. The patient was awakened from
anesthesia, extubated, and brought to the intensive care unit
in guarded condition. Dr. [**Last Name (STitle) **] was scrubbed for the
entire case.

ANGIOGRAPHIC FINDINGS:
1. Normal-appearing abdominal aorta. He had very small
    iliac vessels, all of which are widely patent. There are
    single patent renal arteries bilaterally.
2. Bilateral common iliac arteries, internal iliac
    arteries, and external iliac arteries are very small but
    patent.
3. The vein graft is seen coming off the proximal aspect of
    the left common femoral artery. This appeared to be
    patent with rapid transit of contrast.
4. The right common femoral artery is patent as is the
    right profunda femoris artery.
5. The native superficial femoral artery is diffusely
    diseased. There is a stent within the mid portion of the
    superficial femoral artery. However, the entire
    superficial femoral artery is patent.
6. The pro patent graft is seen coming off the proximal
    portion of the medial portion of the common femoral
    artery and appeared to be patent in its proximal stump.
    However, it occludes for the remainder of course and
    does not reconstitute even on delayed images.
7. The above-knee popliteal artery occludes before the knee
    joint and multiple collateral arteries existed at this
    level which does provide some perfusion to the lower
    leg.
8. Below-knee steel artery is completely occluded, does not
    reconstitute even on delayed images.
9. The anterior tibial artery is heavily diseased in its
    proximal portion. However, in the proximal third of its
    course, reconstituted, and remains patent into the into
    the ankle at which point it abruptly occludes. There is
    a large collateral that exists at this level which
    helped to perfuse the peroneal artery. Some retrograde
    filling of the peroneal artery is seen, although the
    peroneal artery is very diseased throughout its proximal
    half of its course. Distally the peroneal artery runs
    off into the foot with very small plantar and tarsal
    vessels.
10.The posterior tibial artery is occluded throughout its
    entire length.
11.Within the foot itself, the dorsalis pedis artery was
    not seen and is presumed to be occluded. There is a
    lateral tarsal vessel  that does supply the forefoot and
    the plantar circulation provides gives rise to a patent
    but very small plantar arch that gives some perfusion to
    the forefoot.

ADDENDUM:  The distal stump pro patent graft was transected
and ligated with  a 3-0 Vicryl suture.  There is no evidence
of flow within the distal portion of the pro patent graft.
The entire length of the pro patent graft was removed.

                        [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(2) 6039**]

Dictated By:[**Last Name (NamePattern1) 6886**]
EGD report([**2182-9-3**]):
Findings: Esophagus: Normal esophagus.
Stomach:
 Mucosa: Localized discontinuous erythema of the mucosa with no
bleeding was noted in the stomach body. These findings are
compatible with mild gastritis and NGT. These findings can not
explain Hct drop and melena.
Duodenum: Normal duodenum

Colonoscopy ([**2182-9-4**]):
Results:
Impression: Friability and erythema in the rectum
Polyp in the sigmoid colon
Grade 1 internal hemorrhoids
Polyps in the rectum
Diverticulosis of the descending colon and sigmoid colon
Otherwise normal colonoscopy to terminal ileum

Wound cultures:right bypass incision:
 GRAM STAIN (Final [**2182-9-9**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      NO MICROORGANISMS SEEN.

   WOUND CULTURE (Final [**2182-9-11**]):
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.    SPARSE GROWTH.

   ANAEROBIC CULTURE (Preliminary):    NO ANAEROBES ISOLATED.

______________________________________________________


Brief Hospital Course:
This is a 66-year-old man experienced previously rest pain in
his right foot and  had undergone surgery for  a right femoral
patch angioplasty and subsequently right
femoral to below-knee popliteal pro patent bypass graft at
[**Hospital3 **]([**2182-8-23**]). He presented to the [**Hospital1 18**] with
continued rest pain and evidence of limb threat with sensory
loss in the right foot.The patient was consented for a
arteriogram and possible bypass graft nerve to achieve limb
salvage.
After informed consent was obtained, the patient was brought to
the operating room ([**2182-8-24**]). General endotracheal anesthesia
was started. Vancomycin and gentamicin were given intravenously
prior to skin incision. The right leg, both groins, and left
upper extremity was prepped and draped in usual sterile fashion.


OPERATION PERFORMED.:
1. Right common femoral to anterior tibial artery bypass
    with non-reversed greater saphenous vein.
2. Angioscopy and valve lysis.
3. Ultrasound-guided puncture of left common femoral
    artery.
4. Contralateral second-order catheterization of right
    common femoral artery.
5. Abdominal aortogram.
6. Serial arteriogram of the right lower extremity

After surgery the patient was extubated and transferred to the
ICU for recovery. One day after surgery the patient became
increasingly restless and agitated. Given his history of alcohol
abuse he was put on high dose Ativan and  a Dexmedetomidine
drip. Over the course of the next 5 days the patient remained
agitated and delirious requiring large doses of Benzodiazepines.
 On postoperative day five the patient was noted to pass  dark,
loose, guaiac positive stools. His hematocrit  which has been in
the high 20s after surgery dropped to 23/24%. The patient
received 2 units of RBC with a good response. Again  his HCT
dropped one day later from 27 to 24 %. Over the course of the
next view days the patient required multiple  blood transfusions
to stabilize his hematocrit. An EGD and a colonoscopy were
scheduled after his acute alcohol detoxification on the
([**2182-9-3**]). The performed EGD failed to explain his HCT drop and
melena. Colonoscopy was performed one day later and showed a
diffuse continuous friability and erythema in the rectum however
no bleeding was noted.  The patient was weaned and extubated
after colonoscopy. His hematocrit was followed up continuously
over the next couple of days no more bleeding occurred. His
mental status improved and the patient was hemodynamically
stable. No further bleeding occurred so that he was transferred
to the floor on [**2182-9-7**]. DP and PT pulses on both lower
extremities were dopplerable after surgery. Some purulent
discharge and cellulitis was noted over his RLE distal wound.
Wound cultures were sent and the patient was subsequently put on
Vancomycin Ciprofloxacin and Flagyl. Wet to dry dressings have
been changed twice a day. Upon discharge his wound is still with
some drainage. His antibiotic regiment was switched to
Augmentin.
The patients overall condition improved significantly over the
last week. He is hemodynamically stable at the time of
discharge, no shortness of breath and tolerates a regular diet.


Medications on Admission:
Plavix 75', ASA 81', atenolol 50', lisinopril 5', zocor 80',
MTV, folate, fish oil


Discharge Medications:
1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Refill from PCP [**Name9 (PRE) **],[**Name9 (PRE) **]
Phone: [**Telephone/Fax (1) 63941**].
Disp:*30 Tablet(s)* Refills:*0*
7. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 10 days.
Disp:*30 Tablet(s)* Refills:*1*
8. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Refill from PCP [**Name9 (PRE) **],[**Name9 (PRE) **]
Phone: [**Telephone/Fax (1) 63941**]
.
Disp:*30 Tablet(s)* Refills:*0*
10. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY
(Daily): Refill from PCP [**Name9 (PRE) **],[**Name9 (PRE) **]
Phone: [**Telephone/Fax (1) 63941**].
Disp:*30 Tablet(s)* Refills:*0*
11. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
home med.


Discharge Disposition:
Home With Service

Facility:
[**Hospital3 **] VNA

Discharge Diagnosis:
Critical RLE ischemia s/p Right common femoral to anterior
tibial artery bypass with non-reversed greater saphenous vein.

PMH:
1. PVD s/p:
     -Right [**Name (NI) 1793**] PTA/stent ([**8-5**])
     -R CFA endarterectomy w/ bovine pericardial patch

       angioplasty Right BK [**Doctor Last Name **] endarterectomy and [**Location (un) **] patch
       and Right proximal CFA to BK [**Doctor Last Name **] 6mm PTFE ([**8-23**])
2. HTN
3. Lipids
4. Hemachromatosis


Discharge Condition:
Stable


Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions

What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
??????	You should get up out of bed every day and gradually increase
your activity each day
??????	Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
??????	Increase your activities as you can tolerate- do not do too
much right away!

2. It is normal to have swelling of the leg you were operated
on:
??????	Elevate your leg above the level of your heart (use [**3-12**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
??????	Avoid prolonged periods of standing or sitting without your
legs elevated

3. It is normal to have a decreased appetite, your appetite will
return with time
??????	You will probably lose your taste for food and lose some
weight
??????	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

What activities you can and cannot do:
??????	No driving until post-op visit and you are no longer taking
pain medications
??????	Unless you were told not to bear any weight on operative foot:

??????	You should get up every day, get dressed and walk
??????	You should gradually increase your activity
??????	You may up and down stairs, go outside and/or ride in a car
??????	Increase your activities as you can tolerate- do not do too
much right away!
??????	No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
??????	You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over 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
over the area that is draining, as needed
??????	Take all the medications you were taking before surgery,
unless otherwise directed
??????	Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
??????	Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal

What to report to office:
??????	Redness that extends away from your incision
??????	A sudden increase in pain that is not controlled with pain
medication
??????	A sudden change in the ability to move or use your leg or the
ability to feel your leg
??????	Temperature greater than 100.5F for 24 hours
??????	Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions


Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2182-9-19**] 10:15

Call PCP for office visit, to be seen in next 2 weeks.



Completed by:[**2182-9-12**]
{'Other complications due to other vascular device, implant, and graft,Blood in stool,Other postoperative infection,Cellulitis and abscess of leg, except foot,Acute posthemorrhagic anemia,Alcohol withdrawal,Delirium due to conditions classified elsewhere,Chronic total occlusion of artery of the extremities,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Other respiratory abnormalities,Benign neoplasm of rectum and anal canal,Internal hemorrhoids without mention of complication,Diverticulosis of colon (without mention of hemorrhage),Fall from other slipping, tripping, or stumbling,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Benign essential hypertension,Other and unspecified hyperlipidemia,Tobacco use disorder,Hip joint replacement,Other and unspecified alcohol dependence, unspecified,Other iatrogenic hypotension'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: Ischemic right lower extremity

PRESENT ILLNESS: 66 M w/ PVD with rest pain s/p Right [**Name (NI) 1793**] PTA/stent
([**8-5**])-failed.  Presented to [**Hospital **] Hosp for urgent R CFA
endarterectomy w/ bovine pericardial patch angioplasty without
improvement in flow.  This was followed by a Right BK [**Doctor Last Name **]
endarterectomy and [**Location (un) **] patch and Right proximal CFA to BK [**Doctor Last Name **]
6mm PTFE ([**8-23**]).  There was no improvement in rest pain and
patient was transferred to the [**Hospital1 18**] for angiogram and possible
bypass with arm vein.

MEDICAL HISTORY: 1. PVD s/p:
     -Right [**Name (NI) 1793**] PTA/stent ([**8-5**])
     -R CFA endarterectomy w/ bovine pericardial patch

MEDICATION ON ADMISSION: Plavix 75', ASA 81', atenolol 50', lisinopril 5', zocor 80',
MTV, folate, fish oil

ALLERGIES: Percocet

PHYSICAL EXAM: VSS
Gen: NAD, A&OX3
Cardiac: RRR
Lungs: CTA
ABD: soft, non tender
RLE wound: mild erythema, mild swelling, staple line intact
Pulses: B/L fem palp, B/L DP/PT dop

FAMILY HISTORY: N/C

SOCIAL HISTORY: Retired carpenter, 50 pack year smoker, currently smoking, 6-8
beers per day.  Married, lives at home 

### Response:
{'Other complications due to other vascular device, implant, and graft,Blood in stool,Other postoperative infection,Cellulitis and abscess of leg, except foot,Acute posthemorrhagic anemia,Alcohol withdrawal,Delirium due to conditions classified elsewhere,Chronic total occlusion of artery of the extremities,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Other respiratory abnormalities,Benign neoplasm of rectum and anal canal,Internal hemorrhoids without mention of complication,Diverticulosis of colon (without mention of hemorrhage),Fall from other slipping, tripping, or stumbling,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Benign essential hypertension,Other and unspecified hyperlipidemia,Tobacco use disorder,Hip joint replacement,Other and unspecified alcohol dependence, unspecified,Other iatrogenic hypotension'}
