DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
HISTORY OF PRESENT ILLNESS: This (XX)-year-old male was admitted for a pulmonary embolism. The patient's daughter is present and relates most of the history. The patient apparently was at an outside facility, undergoing a mesenteric artery bypass, where it was noted in the recovery room that his feet and legs were turning blue. It was decided at that time to watch the feet, as he was in no condition for any further surgery. After 2 weeks, he was transferred to this facility, where he has had much improvement in the color and pain in his feet. This past Wednesday, however, it was noted that he had a couple of red spots on his left heel. The patient states that the left heel is only slightly sore when compared to the right. He has been wearing PRAFO boots for the past 12 days while at the rehab center, and therefore, every attempt was made to keep pressure off of his heels. He states that the right second toe has been about the same over the last few weeks; however, the left second toe has fluctuated quite a bit. He has been using Lidoderm patches for pain, which again he states is improving.
REFERRING PHYSICIAN: John Doe, MD
HISTORY OF PRESENT ILLNESS: This (XX)-year-old male was admitted for a pulmonary embolism. The patient's daughter is present and relates most of the history. The patient apparently was at an outside facility, undergoing a mesenteric artery bypass, where it was noted in the recovery room that his feet and legs were turning blue. It was decided at that time to watch the feet, as he was in no condition for any further surgery. After 2 weeks, he was transferred to this facility, where he has had much improvement in the color and pain in his feet. This past Wednesday, however, it was noted that he had a couple of red spots on his left heel. The patient states that the left heel is only slightly sore when compared to the right. He has been wearing PRAFO boots for the past 12 days while at the rehab center, and therefore, every attempt was made to keep pressure off of his heels. He states that the right second toe has been about the same over the last few weeks; however, the left second toe has fluctuated quite a bit. He has been using Lidoderm patches for pain, which again he states is improving.
PAST MEDICAL HISTORY: Significant for hypertension, chronic obstructive pulmonary disease, hyperlipidemia, history of lung cancer, right thigh wound with MRSA, peripheral arterial disease, recent aortomesenteric bypass, and a history of prostate cancer.
MEDICATIONS: See nursing intake sheet.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
PHYSICAL EXAMINATION:
VITAL SIGNS: Stable. The patient is noted to have a 101-degree temperature, which is the T-max.
INTEGUMENT: Reveals cyanotic, pre-gangrenous changes to the distal tip of the right second digit from the distal interphalangeal joint out. There is a small wound on the dorsum of the right second digit, which is healthy. There are no signs of infection or any drainage or odor. There is peeling of the epidermis to the right second digit with healthy skin beneath this. There are patchy cyanotic ischemic changes to the distal tip of the left hallux, left second and third digit, and dorsal left fifth digit just proximal to the nail. There is a larger patchy area posterolaterally on the left heel. The skin is intact, however, with no drainage or gross signs of infection noted.
VASCULAR: Examination reveals nonpalpable dorsalis pedis and posterior tibial pulses, bilateral feet. Hair growth is absent with cool, shiny, atrophic skin. Moderate nonpitting edema is noted bilaterally.
NEUROLOGIC: Examination is intact to light touch.
MUSCULOSKELETAL: Examination reveals tenderness to palpation, posterolateral left heel and distal right second digit. The lesser digits on both feet are mildly contracted in a semirigid manner. There is no other obvious deformity noted.
LABORATORY DATA: WBC 11.8, hemoglobin 10.6, hematocrit 33.4, and platelets 632,000. CRP 11.98. Sedimentation rate 86. Bilateral lower extremity duplex venous ultrasound is negative for lower extremity DVT. Arterial flow study of both lower extremities without exercise reveals probable right SFA occlusion with an ABI of 0.78 on the right side. There is a probable left SFA occlusion with an ABI of 0.46 on the left. Absent digital waveform is noted to the right second digit, suggesting thrombosis or embolic phenomenon.
IMPRESSION:
1. Ischemic/cyanotic digits, bilateral feet and left heel.
2. Peripheral arterial disease, bilateral lower extremities.
RECOMMENDATION: Following examination of both feet, light excisional debridement of all loose tissue was performed to the right second digit. I would recommend keeping the toes open to air and only cover with a Lidoderm patch p.r.n. pain. Ensure that both of his heels are off of the bed, as they are currently, on pillows or in a PRAFO. The patient is going for an angiogram and possible percutaneous transluminal angioplasty today per Interventional Cardiology. Hopefully, if they discover a blockage and it can be opened, the left heel and the toes will improve. I would allow them to demarcate and continue to monitor them, as they are not infected and the patient does not have severe intractable pain. Therefore, there is no immediate cause for debridement or amputation. I will follow this patient during his hospital stay.
Thank you for allowing me to participate in the care of this patient.
