959086752
PUOMC
6824024
094907
812890
2/1/2000 12:00:00 AM
Discharge Summary
Signed
DIS
Report Status :
Signed
DISCHARGE SUMMARY
NAME :
RATHELIFE , TIEANAKI B
UNIT NUMBER :
342-07-28
ADMISSION DATE :
02/01/2000
DISCHARGE DATE :
02/08/2000
PRINCIPAL DIAGNOSIS :
Non-healing ulcer on the right leg .
PRINCIPAL PROCEDURE :
Right fem to below knee pop bypass graft .
HISTORY OF PRESENT ILLNESS :
This patient is an seventy eight year old female with history of peripheral vascular disease who is status post above knee to fem pop bypass graft with 6 millimeter PTFE .
This operation was performed for two months of increased rest pain .
Her pain resolved after surgery and she has been doing well since , although at baseline now she is minimally ambulatory from bed to commode .
For the past couple of months the patient has had a non-healing right dorsal foot ulcer which has been increasing in size and started as a pin hole and she does not recollect any trauma , as similar small ulcers developed on the left foot as well around the same time , but that has subsequently healed .
The ulcer was managed conservatively at Har Hospital by Dr. Holes with Silvadene b.i.d. lower extremity non-invasive study obtained at that time showed poor distal right extremity perfusion .
The patient was referred back to Dr. Pop for the possibility of a revascularization procedure .
She is status post angiography today .
She has just finished a ten day course of Ciprofloxacin .
She denies any fevers or chills .
She does have rest pain in the right foot and ankle .
PAST MEDICAL HISTORY :
Significant for Guillain-Barr syndrome , Lupus , status post multiple decubiti , peripheral vascular disease , status post right total knee replacement and status post cholecystectomy , status post hysterectomy , status post goiter and left lung fibrosis , status post methicillin resistant Staphylococcus aureus pneumonia .
MEDICATIONS ON ADMISSION :
Prednisone 5 every other day , alternating with ten every other day .
Trental 400 milligrams t.i.d. , Cytotec 100 milligrams t.i.d. , Ativan 2 milligrams q.h.s. Darvon 65 milligrams two q.i.d , Relafen 500 milligrams b.i.d , Vitamin E , Prilosec 20 milligrams once a day , Zantac 150 milligrams b.i.d , Lasix 120 milligrams every other day PRN edema .
Didronel 1 q day which has been on hold .
Proventil inhaler via nebulizers 0.5 milligrams with Atrovent .
ALLERGIES :
The patient is allergic Ampicillin , Tylenol , Clinoril , Biaxin , Codeine , Sulfa and Aminophylline .
PHYSICAL EXAMINATION :
She is afebrile , her vital signs are stable .
Her pupils equal round reactive to light and accomodation , normocephalic , atraumatic , extraocular muscles intact .
Neck , she has II+ bilateral carotids , no bruits , no jugular venous distention .
Lungs decreased breath sounds at bilateral bases with minimal expiratory crackles on the right .
Abdomen , soft , non-tender , non-distended , normal active bowel sounds .
Extremities on the right , she has a II+ femoral , no distal pulses beyond that .
On the left she has a II+ femoral and II+ popliteal , no distal pulses beyond that .
She has on her right ankle anteriorly a four centimeter ulcer with necrotic base .
Minimal surrounding erythema .
She is able to wiggle her toes bilaterally .
Sensation is intact bilaterally .
Her legs are tender to touch bilaterally .
Her angiography showed a right proximal popliteal occlusion , anterior tibial dominant foot vessel .
Small posterior tibial occlusion on the distal calf and a small peroneal goes down to the ankle .
On a rectal examination she is guaiac negative , no masses and no gluteal ulcers or decubiti .
HOSPITAL COURSE AND TREATMENT :
The patient was admitted and taken to the operating room on the following day and she underwent a right fem to below knee popliteal bypass graft using a six millimeter ring PTFE .
She had a strong popliteal doppler pulse intraoperatively and good PVR on the right postoperatively .
The patient did well in the postoperative period .
She was afebrile , her vital signs were stable .
She was making adequate urine output anywhere between 20 to 50 ccs an hour .
Her hematocrit was 26.8 and she was transfused 1 unit of packed red blood cells .
Her diet was advanced from clears to a diet as tolerated .
On postoperative day two the patient was noted to have some swelling in her left lower extremity and this was felt to be a hematoma secondary to her PVR cuff .
There is mild amount of surrounding erythema and the patient was started on Ancef at that time .
The patient was seen by physical therapy .
The area of erythema on her left leg enlarged slightly and the patient was placed on Vancomycin for several days after which time her erythema again began to decrease .
Her right foot remained warm .
She had wounds which were clean , dry and intact and the patient was stable from a respiratory standpoint using her respirator at night .
The patient required an additional blood transfusion during her hospital stay as her hematocrit had decreased to 27 on postoperative day three .
The patient while in bed had her legs elevated .
The patient was tolerating a general diet , she was voiding on her own and the patient was discharged to home as her daughter is a nurse .
She was discharged with PO Keflex that she was to take for the next ten days .
The patient is to follow up with Dr. Pop in one week and the patient was afebrile with stable vital signs at the time of discharge .
LAYMIE ASLINKE , M.D.
DICTATING FOR :
Electronically Signed EDRY R YELLOW , M.D.
03/16/2000 13:21
_____________________________ EDRY YELLOW , M.D.
TR :
nw
DD :
02/09/2000
TD :
02/12/2000 1:41 P
cc :
EDRY R YELLOW , M.D.