Specimens none Complications The patient tolerated the procedure well with no

Specimens none complications the patient tolerated

This preview shows page 16 - 19 out of 48 pages.

Specimens: none Complications: The patient tolerated the procedure well with no complications. Disposition/condition: To 4W SICU in stable condition Findings: End-to-side ABF created from the immediate infrarenal aorta with preservation of the bilateral accessory renal arteries and the IMA. Profunda only runoff on the left. Good, graft dependent pedal signals at case completion, better on the right than left. 4:49 PM Revision History ... Date/Time 8:42 AM 4:53 PM View Details Report about:blank 'Jser •, MD ., MD Addend Sign Action
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Ph y sician A dd en d u m MRN Sex Female Surgical Critical Care Progress Notes DOB Page 1 of 6 Age 60 Service date: 5:03 PM .. �: lated _ enc o unter: Admission (Discharged) fr om _ 1n __ UF _ 55MS · · · ·· · · - -- ·· ·· - - - - - · · ·· - ·· · ·- · · · - - · · ·· · · · · · · ···- ·· ··· · · · · · · · ····· · · - · · · · · · ·· · · · ·· ·· · ··· · · ·· · · · ··· .. · · · ···· · · · · ··· · Surgical CritiGal Care Departments of Anesthesiology, Emergency Medicine and Surgery Progress Note Admit Date: LOS: 1 day Post op Day: O Reason for ICU Admission/ Perioperative Course: 60 y/o F transferred from OSH on for evaluation of LLE ischemia with dry gangrene of L 1st and 2nd toes and L posterior heal presents s/p open aorto-bi-femoral bypass with dacron graft today. OR Airway Mac 3, Grade 1 Easy mask, easy airway EBL 750ml, XL 2.5L, Albumin 5% 500ml, UOP 565ml Past Medical History: Past Medical History Diagnosis CAD (coronary artery disease) HLD (hyperlipidemia) S/P CABG x 4 PVD (peripheral vascular disease) OM (diabetes mellitus) Past Surgical History: Past Surgical History Procedure Coronary artery bypass graft Social History: History Smoking status Former Smoker -- 1.50 packs/day for 20 years Quit date: Smokeless tobacco Not on file History Alcohol Use: Drug Use Subjective: I have reviewed the patient course and previous notes. Patient Active Problem List Diagnosis PVD (peripheral vascular disease) CAD, multiple vessel about:blank Date Laterality Date Not on file Not on file
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.. • HLD (hyperlipidemia) • Left Lower limb ischemia • Left Foot Dry Gangrene OM (diabetes mellitus) • Pressure ulcer of left heel • HTN (hypertension) Current Hospital Medications Reviewed Review of Systems Complains of abdominal pain, denies any chest pain, SOB, abdominal pain, HA, N/V Objective Data and Assessment: CNS/Neuro: Exam: AAOx 3, Pupils: equal and reactive bilaterally 3mm, Focal Signs FCC x 4 Rass Score: Pain Score: Pain Scale (UF) - DVPRS: Patient Asleep CAM Score: Sedation/Pain control: Dilaudid PCA Sedation Protocol: No Delirium Protocol: No Respiratory: No results found for this basename: PHART, PCO2ART, PO2ART, HCO3ART, BDEFART, O2SATART, in the last 72 hours SpO2: 98 % ( 1656) 02 Flow Rate (Umin): 2 Umin Resp: [8-17] Pulmonary exam:Clear to auscultation bilaterally Cardiovascular: BP: (106-123)/(52-67) Pulse: [77-92] Rhythm: Normal Sinus Cardiac exam: S1 and S2 present no m/r/g appreciated.
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  • Spring '14
  • CherylA.Wenger
  • External iliac artery, Common iliac artery, Gangrene, Coronary artery bypass surgery

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