DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Worsening left lower extremity ulcers.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old who resides in a local life care facility. She reports that she has had a chronic ulcer of her left lower extremity for the last 30 years. Over the past 30 years, she has had an extensive array of therapies for this nonhealing, extremely chronic leg ulcer. These therapies have included a variety of local therapies, hyperbarics, multiple hospitalizations, and innumerable antibiotic courses. In spite of all these efforts, these lesions were never completely healed, though until recently the patient was able to ambulate and have some reasonable quality of life with the left lower extremity. She reports in the recent months, she has had more pain, unsteadiness, and inability to ambulate, and has been essentially confined to a wheelchair for the past four months. She is admitted today with worsening swelling and pain of the left lower extremity and particularly the area around the chronic ulcerations. She was treated as an outpatient at the life care facility with a course of ceftriaxone as well as good local care and in an attempt to turn the tide of this worsening ulcerative process involving the left lower extremity, but this was unsuccessful. The patient denies any recent fevers, chills, sweats, worsening headaches, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea or genitourinary symptoms.
PAST MEDICAL HISTORY:
1. Peripheral vascular disease.
2. Lymphedema, left greater than right lower extremity.
3. History of DVT in the past.
4. Diabetes mellitus.
5. Degenerative joint disease.
6. Coronary artery disease.
ALLERGIES: The patient has no known allergies.
SOCIAL HISTORY: The patient lives at the life care facility. She does not smoke nor drink.
REVIEW OF SYSTEMS: Review of systems was done in its entirety and the pertinent positives and negatives have been included in the history of present illness.
FAMILY HISTORY: Noncontributory and not relevant.
PHYSICAL EXAMINATION: At this time, reveals an elderly Hispanic woman who appears somewhat younger than her stated age, lying supine comfortably in her hospital bed. She is alert, conversant, and able to give a good history. She is currently afebrile than she has been since the time of admission. Blood pressure of 104/52, pulse 80, and respiratory rate 18 and unlabored. Examination of the head reveals no evidence of trauma. The eyes are notable for bilateral arcus senilis and diminished vision bilaterally, which the patient reports is due to macular degeneration. Examination of the oral cavity reveals no thrush or oral leukoplakia. There are no pharyngeal abnormalities present. The patient’s neck is without JVD and there is no supraclavicular adenopathy. Lung examination is clear. Cardiac exam reveals regular rate and rhythm without murmurs, rubs or gallops. The patient’s abdomen is soft and nontender without organomegaly and without ascites. Examination of the lower extremities is notable for venous stasis changes on both feet. There are diminished peripheral pulses in both lower extremities as well and, in fact, we cannot palpate any pulses in the left lower extremity below her level of the femoral artery. The patient’s major abnormal physical findings were on the left leg, below the knee. There is an area of erythema and diffuse tenderness, which extends below the level of the mid chin. There are three large purulent venous ulcers; the largest one measuring 8.5 x 2.5 cm. Two other ulcers are present, one on the dorsum and one on the medial aspect of the ankle. These are approximately 2.5 cm in circumference and all three of these are covered with a purulent exudative material.
LABORATORY STUDIES: White count was 5000, hematocrit 42, creatinine 0.6, AST of 44. Two blood cultures have been done, and they are negative at this point. A Gram stain obtained from the purulent material from the left foot has revealed 3+ gram-negative rods. A chest x-ray shows cardiomegaly, which is old without an infiltrate.
IMPRESSION: This (XX)-year-old woman has had an impressive 30-year history of nonhealing stasis ulcers on her left leg. She now reports that these ulcers have progressed to the point where they are the worst they have ever been. This is in spite of good local care at the extended care facility as well as her recent course of ceftriaxone. At this point, all three of these are chronic ulcers. They appear to be heavily superinfected, and the wound care team has initiated a program of Accuzyme topical therapy. In addition to this, systemic antibiotics will be necessary. Zosyn has already been started and we think that is the reasonable choice pending evaluation of what these gram-negative rods are, but it is certainly possible that highly resisting gram-negative rods will be found given the pretreatment with ceftriaxone. One question which obviously stands out in this patient is whether or not her left lower leg, below the knee, is still viable given the history of worsening ulcers, which now seem refractory to conventional measures.
RECOMMENDATIONS:
1. Agree with Zosyn.
2. We will reevaluate when we have back the culture information tomorrow.
3. We agree with the plans for local care as outlined by the wound care team.
Thank you very much for allowing us to see this patient in consultation.
