DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
ADMISSION DIAGNOSES:
1. Arterial insufficiency, both lower extremities.
2. History of 56% stenosis of the left external iliac artery.
3. Right superficial femoral artery occlusive disease.
4. Coronary artery disease.
5. Diabetes.
6. Hyperlipidemia.
DISCHARGE DIAGNOSES:
1. Percutaneous transluminal angioplasty of the left external iliac artery.
2. Right femoropopliteal artery bypass.
3. Aortogram with runoff from the common femoral artery.
4. Arterial insufficiency, both lower extremities.
5. History of 56% stenosis of the left external iliac artery.
6. Right superficial femoral artery occlusive disease.
7. Coronary artery disease.
8. Diabetes.
9. Hyperlipidemia.
HOSPITAL COURSE: This is a (XX)-year-old male who was seen in the office by Dr. John Doe complaining of pain in both lower extremities, left worse than the right, after walking about 100 to 150 feet. His problem began approximately four years ago and has progressively worsened. He has a history of smoking a pack a day for 40 years but quit about eight years ago. He has taken Trental 400 mg twice a day for a number of years but has not had significant improvement in his claudication.
He underwent a lower extremity Doppler on MM/DD/YYYY. At rest, ankle-brachial indices are 0.82 on the right and 0.96 on the left. However, following exercise, these fell to 0.46 on the right and 0.52 on the left indicating hemodynamically significant lower extremity arterial occlusive disease bilaterally. He was admitted on MM/DD/YYYY for an arteriography of the abdominal aorta and bilateral lower extremity runoff.
On MM/DD/YYYY, he presented to the office for followup, which showed 50-60% stenosis of the left external iliac artery and a 75% stenosis on the right superficial femoral artery. At that time, Dr. John Doe had discussed the procedure for right femoropopliteal artery bypass and also a left iliac artery percutaneous transluminal angioplasty with stent, and the patient had agreed to proceed with this. He underwent the above procedures and did well postoperatively.
He was discharged to home on his home medications and instructed to follow up in Dr. John Doe’s office approximately one week after discharge.
