DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Severe peripheral vascular disease with ulceration of bilateral lower extremities.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male, well known to this facility, who has a history of right lower extremity fem-pop bypass as well as amputation of the toe secondary to peripheral vascular disease. He does have significant history of diabetes, hypertension, dyslipidemia, and also has a history of coronary artery disease. The patient was seen in the office yesterday where it was found that he had significant necrosis of his left toes, including significant amount of purulence and malodorous discharge. The patient also has a significant nonhealing ulcer to the left heel involving skin and much of the soft tissue as well as the heel pad. This also has a malodorous discharge as well as being purulent and boggy in nature. The patient also has a significant nonhealing ulcer to the right heel, which shows possible evidence of deep tissue penetration and possible osteomyelitis. It was discussed with the patient and the patient’s daughter that he will most likely benefit from above-the-knee amputation on bilateral lower extremities secondary to the fact that he is not ambulatory and the fact that his peripheral vascular status significantly limits his ability of healing further amputations.
PAST MEDICAL HISTORY: Significant for coronary artery disease, peripheral vascular disease, amputation, history of diabetes, hypertension, dyslipidemia, as well as end-stage renal disease.
PAST SURGICAL HISTORY: Significant for coronary artery bypass grafting, right lower extremity femoral popliteal bypass, amputation of toes, creation of right arm AV fistula.
ALLERGIES: NKDA.
HOME MEDICATIONS: Include Coumadin, Toprol, Zocor, Glucotrol, Trental, and aspirin.
SOCIAL HISTORY: The patient does have a significant history of smoking, however, quit approximately 30 years ago. No history of alcohol or drug abuse. The patient is currently a nursing home resident due to significant physical limitations as well as mental status changes recently.
FAMILY HISTORY: The patient denies any history of end-stage renal disease or peripheral vascular disease.
REVIEW OF SYSTEMS: Fourteen-point review of systems was performed. Pertinent positives as above in the HPI. The patient currently denies any chest pain, shortness of breath, difficulty breathing, orthopnea or PND. The patient denies any abdominal pain, nausea, vomiting, diarrhea, constipation or blood in the stool. The patient denies any hematuria or dysuria. The patient denies any unexpected weight loss, weight gain or other significant changes.
PHYSICAL EXAMINATION: The patient’s current vital signs are temperature 98.2, respirations 18, blood pressure 98/60, and pulse rate of 120. The patient is chronically ill appearing, however, in no acute distress. Normocephalic and atraumatic. Extraocular muscles are intact. Pupils are equal and reactive. The patient does have poor dentition, however, no evidence of any oral lesions or pharyngitis present. Neck is soft and supple. The patient has easily palpable bilateral carotid pulses. No evidence of carotid bruits on auscultation. The patient is currently in atrial fibrillation with rapid ventricular rate approximately of 122 as confirmed by electrocardiogram. There are no murmurs or rubs appreciated. Lungs are clear to auscultation bilaterally. No evidence of any wheezing, rales or rhonchi present. The patient does have equal and symmetric chest wall expansion. Abdomen is protuberant; however, soft and nontender. No evidence of any organomegaly or abdominal masses appreciated on physical examination. On lower extremities, the patient has 2+ bilateral femoral pulses. No appreciable popliteal, dorsalis pedis or posterior tibialis pulses on lower extremities. As mentioned in the history of present illness, the patient does have significant necrosis to the toes of the left lower extremity as well as significant nonhealing ulcer to his left foot. Both the ulcer and the necrotic toes demonstrate significant purulence as well as significant erythema involving the soft tissues. The right lower extremity demonstrates a circular nonhealing lesion on the lateral aspect of the right heel. Again, there is significant amount of erythema present as well as some slight purulence with significant evidence of nonhealing ulceration. The patient does have a significant amount of erythema involving the bilateral lower extremities, left greater than right, primarily involving the anterior aspect. The patient’s upper extremities have easily palpable brachial and radial pulses. He does have an AV fistula in the right arm, which has been recently accessed by dialysis. On neurologic examination, the patient is alert, however, is not currently oriented to person or place. This is the patient’s normal status, according to his daughter, in the recent weeks with no significant changes noted.
IMPRESSION AND PLAN:
1. Severe peripheral vascular disease with necrosis and ulceration of bilateral lower extremities. The patient would benefit significantly from bilateral above-the-knee amputations secondary to the fact that the significance of his peripheral vascular disease will greatly inhibit any healing for further amputations. Also the fact that the patient is nonambulatory at this time and will unlikely become ambulatory in the future precludes the need for consideration of a lower limb prosthesis. These options were discussed with the daughter as well as significant risks associated with surgery, including risk of infection, pneumonia, acute myocardial infarction, stroke, and possible death. All these risks again were discussed with the patient and the patient’s daughter. The patient’s daughter expressed understanding of all these and wished to proceed.
2. Coronary artery disease. The patient is currently being evaluated for suitability for surgery; however, it is not felt that the patient’s coronary status will anyway affect the decision to proceed with surgery.
