Michael Tu

Full H/P #2
CC: black toe
HPI: MH is a 70 yo Caucasian female with hx poorly controlled DM, recurrent LE cellulitis and
osteomyelitis s/p R 5th amputation, PVD including Subclavian Steal Syndrome and L femoralpopliteal bypass and L popliteal endarterectomy, CAD, CVA, HTN who presents 4/3/15 to the
ED with LLE cellulitis and L great toe gangrene. She states the toe started to turn black on
3/30/15 and was associated with fevers as high as 102, nausea and vomiting, and loss of
appetite. She reports that she had stopped taking all her medications except clopidogrel and
Lantus for two weeks prior. She came to the ED with tachycardia and leukocytosis and ESR
102. XR L foot showed osteomyelitis of L great toe. Blood cultures were drawn and she was
started on IV meropenem.
MH was also admitted in December 2014 for osteomyelitis of her L great toe, and blood
culture then was negative. She completed a 6 week course of clindamycin and levofloxacin. On
October 2014 she was found to have osteomyelitis of R 5th digit requiring amputation, bone
culture with E. fecalis. She then completed two weeks of cefazolin and metronidazole and
continued on levofloxacin and clindamycin as an outpatient.
PMH:
DM2
CAD
CVA
Subclavian steal syndrome
RLE osteomylitis
HTN
Past Surgical Hx:
Right 5th MT Amputation 2014
L femoral-popliteal bypass 2007
L popliteal endarterectomy 2007
Cholecystectomy in 1990
Hysterectomy in 1972
Family Hx:
-Father with DM, CAD, PVD
-Mother with CAD, PVD
-Denies other family members with stroke, diabetes, cancer.
Social Hx:
-Lives at home with husband
-Manages her own medications
-smokes 1ppd for 40 years but claims to have quit 3 weeks ago

-Denies alcohol, heroine, marijuanna, and cocaine use.

Allergies:
-Penicillin, hives,
-Sulfa drugs, hives
-Vancomycin, turns red. However this is a side effect of infusion rate rather than allergy.
Medications:
1) Albuterol: 2 Puffs Inhaled Every 4 hours as needed
2) Aspirin 81 mg Chew Tab
3) Clindamycin 300 mg Cap By Mouth 3 times daily for 6 Weeks
4) Clopidogrel 75 mg Tab :1 Tab By Mouth Daily
5) Enteral Oral Product (Boost Glucose Control) : Give 1 carton TID
6) Esophagitis Mixture
Hydroxides Susp. 15 mL PO BID prn
7) Glucose Test Strips Aviva : To be used only with Aviva Meter
8) Insulin Aspart
9) Insulin Glargine Inj (Lantus) : 8 units qHs
10) Levofloxacin 750 mg Tab (LEVAQUIN) : 750 MG By Mouth Daily for 6 Weeks,
11) Metoclopramide 5 mg PO TID prn
12) Ondansetron 4 mg Disint Tab
13) Pravastatin Sodium 40 mg Tab (PRAVACHOL) : 1 tablet (40 mg) by oral route once daily
14) Ranitidine 150 mg Tab (ZANTAC) : 1 Tab By Mouth 2 times daily
15) Syringe U-100 Insulin
16) diphenhydrAMINE HCl 25 mg Tab : 1 Tab By Mouth Every 8 hours
17) oxycodone HCl 5 mg / Acetaminophen 325 mg Tab
Review of Systems:
She claims to have headache, but 10 point review of systems otherwise negative.
Physical Exam:

Tmax 38.1C (100.6F), Tc 36.9C (98.5F), P 93-120 (99), R 16-20 (18), BP 115/52 - 163/83 (115/83)
Gen: AAO, NAD
HEENT: PERRL, MMM
Resp: CTAB, no wheezes
CV: Tachycardic, regular rhythm, +1 LLE pulse
Abd: Soft, NT, ND
LE: RLE without erythema, stitches along R lateral foot, LLE with black eschar of L. great toe and some
2nd toe involvement at plantar, surrounding erythema up to L. calve, no visible purulence
Neuro: AOx3, strength full, sensation intact, moving all four extremities
psych: affect pleasant and mood congruent; dishevelled appearance

Physical Exam
General: sitting up in bed, in no acute distress, appears older than stated age
HEENT: NC/AT, EOM grossly intact, sclera anicteric, conjunctiva pink, PERRL, Mucus
membranes dry, oropharynx clear, poor dentition
CV: RRR, S1/S2 normal
Resp: Clear to auscultation bilaterally

Abd: soft, nontender, nondistended, BS+, no guarding or rigidity

Ext: R LE - R 5th digit amputation site clean and well healed with intact intact DP and TP pulses.
L LE - swelling-prominent over dorsum of left foot and ankle
erythema and warmth-present on dorsum of left foot extending to 1/2 way up leg.
pain-most prominent at ankle joint and proximal to gangrene.
dry gangrene of Left great toe with 2nd toe with exposed bone, warmth and pain of the L
pulses- thready DP, PT pulses on left.
Pulses: 2+ present and equal bilaterally both upper extremities; 2+ DP TP on right , 1+ DP TP
on left.
Neuro: alert and oriented x3; sensation grossly intact in both lower extremities; CN 2-12 grossly
intact; able to move all extremities but not moving LE much at all due to pain
Labs/Imaging/Procedures
128 | 98 | 23
---------+---- 392 ON 03 Apr 2015
4.6 | 23 | 0.77

Ca: 8.3 (9.1) Mg: 2.0(2.0)

WBC: 13.2<-12.8 <- 15.7
Hgb: 9.2 (9.5)
Hct: 28
PLT: 230 (224)
MCV: 83 (81)
PT/INR: 10.7/1.1
ESR: 105
A1c:14.2
WBC 12.8
Blood cx 3/31 GPC in chains ( bottles) E. faecalis
Blood cx 4/1: NGTD
XR L foot 3/31
Impression: Cortical irregularity and bone destruction centered at the medial aspect of the first
interphalangeal joint compatible with osteomyelitis. There is acroosteolysis of the distal phalanx
which is also completely subluxed dorsally onto the metatarsal neck. The overlying soft tissues
of the foot appear mildly swollen. - per radiology
Echo
CONCLUSION:
Left ventricular cavity size normal.
No obvious regional wall motion abnormalities.

Left ventricular ejection fraction at the lower limits of normal.

Normal right ventricular global systolic function.
Other chambers normal in size.
Mild tricuspid regurgitation (normal variant).
Right ventricular systolic pressure estimated to be 40-45 mm Hg.
Pulmonic valve not well visualized. No functional abnormalities.
Other cardiac valves structurally and functionally normal.
No vegetations seen (suggest transesophageal echo if suspicion high).
No pericardial effusion.
Normal aorta at the level of the sinuses.

Aortofemoral CTA:
Impression
1. No abdominal aortic aneurysm or flow-limiting stenosis. No critical mesenteric or renal artery
stenosis. 2. The right superficial femoral artery and popliteal artery are entirely occluded. A widely
patent bypass graft begins at the right common femoral artery bifurcation and extends to the anterior
tibial artery. 1.4 cm fusiform aneurysm of the proximal bypass graft. The anterior tibial artery is the
only runoff to the right foot. 3. 8 cm moderate to severe stenosis of the proximal left superficial
femoral artery. Occlusion of the left above-the-knee popliteal artery with reconstitution at the level of
the knee joint. Two-vessel left-sided runoff. -per radiology

Arterial Doppler
Conclusion:
Right leg presents with essentially normal distal perfusion at rest. ABI =+1 with biphasic flow at
ankle.
Left leg presents with moderately diminished distal perfusion at rest. ABI = 0.46 with monophasic flow
at ankle.
There is >15% change since 10/20/2014 -per radiology

C-reactive protein: 16.9

TTE (vascular sugery wanted for eval of endocarditis): pending
Protime:
Assessment and Plan
70 yo with vasculopathy and poorly controlled DM recurrent soft tissue and bone infection of
LE's presents with fever, leukocytosis, elevated ESR and osteomyelitis of R 1st digit and exam
findings consistent with dry gangrene
# Sepsis secondary to Diabetic foot infection and osteomyelitis
-SIRS criteria met: fever, tachycardia, leukocytosis
-Vascular surgery on board and planning to amputate during this admission. may plan to revascularize before amputation.
-ID consulted; continue Meropenem 1gm IV Q12H and linezolid.
-Wound care consulted
-Bedrest, elevation of limb and off-loading
-Will repeat blood culture in 48 hours
# DM II

-poorly controlled; HbA1c: 14.3 (4/2015)

-BG have ranged from 244-582 this admission. BG today 392.
-To prevent infectious complications and delayed wound healing post-operatively, will increase
Insulin Glargine 12U-->18U, Lispro 6U-->8U. Goal to keep BG<250.
-SSI
-Accuchecks
# PVD
-40 pack year history and claims to have quit 3 weeks ago
-Vascular surgery on board; may revascularize prior to amputation
-Continue home aspirin, clopidogrel, and statin
-Lipid panel pending
#Pseudohyponatremia
-related to hyperglycemia and will continue to monitor daily BMPs
-Corrected Sodium = Measured sodium + (((Serum glucose - 100)/100) x 1.6)
#COPD
-stable and will continue Albuterol prn
#Malnutrition
-pre-albumin low at 3.6
-Nutrition consulted; recommended Boost supplementation QPC TID
#skin breakdown of sacrum
-wound care consulted; appreciate assistance
#FEN/GI
-continue IVFs
-will correct for Na to account for pseudohyponatremia, monitor morning BMPs
-Carb conscious diet
#PPX
Lovenox
FULL CODE
Dispo: continue current management on Yellow medicine team; patient will remain inpatient for
vascular procedure/amputation