Peripheral vascular disease/arterial insufficiency

Case Study Assignment #1

 

The following case study contains many medical terms that need to be identified, defined and rewritten in layman’s terms. Please see the directions for the case study in regards to paper structure and format.

 

Discharge Summary:

 

Admitting Dx:

1. worsened gangrene of the third and fifth phalanges left foot
2. Peripheral vascular disease/arterial insufficiency
   1. Status post femorofemoral bypass 3/6/02
   2. Left lumbar discectomy
   3. Left groin exploration
   4. Profundoplasty and left profondus endarterectomy
3. Diabetes mellitus type 2
4. CAD, status post AWMI 1996
5. Status post PTCA of LAD
6. Cerebral vessel disease status post CVA 1997
7. History of gout
8. Renal insufficiency with baseline creatinine of 1.7
9. History of ischemic cardiomyopathy with left ventricular dysfunction
10. Status post left hip fx 1990
11. S/P LLE arterial bypass graft

 

History:  This 64 year old male with type 2 DM and PVD, S/P femorofemoral bypass in early March along with the above surgeries for #3,5 phalangeal gangrene on the left foot was followed in the vascular surgery clinic on the 27^th of March, with complaints of recurrence of pain in the same phalanges. The patient was promptly sent to the vascular lab where it was revealed occluded left posterior tibial, anterior tibial and peroneal arteries. Therefore, plans were made for the pt to be brought to the OR for amputation of #3,5 phalanges and femoral to peroneal bypass.

 

Physical Findings:  Pt was in Sinus Rhythm. He was afebrile. Lungs were clear. CXR was WNL and all lab work was WNL.

 

Hospital Course:  Patient was taken to the OR on 3/27 where Dr. Rooter with the assistance of Dr. Moo performed the femoral to peroneal bypass using a graft, followed by amputation of the 3^rd and 5^th phalanges. In addition, an intraoperative angiogram was done discovering a thrombosis in his previous femorofemoral bypass and a thrombectomy was performed resulting in good blood flow to the left foot. Following this the patient was transferred to the ICU in stable status where he remained for the next few postop days being watched closely by cardiology for any sx of CHF. The patient remained stable postoperatively and anticoagulation was initiated while the pt remained in ICU. On the morning of postop day three, the patient experienced angina requiring cardiac enzymes which were slightly elevated and cardiology recommended the patient undergo a coronary angiogram using a brachia approach. The angiogram finding showed a 95% mid LAD lesion. This was stented and reperfusion was accomplished to the LAD. The patient tolerated the procedure well and was readmitted to ICU in stable status. He was restarted on anticoagulant therapy and plans were made for the patient to be discharged three days later with home health nurse visits per his HMO and PT. The patient’s amputation sites were monitored and granulating well without any purulent drainage. The patient remained afebrile with his WBC level WNL and his cardiac enzymes improved to normal.

 

Laboratory results:  WBC, RBC counts WNL, Hgb WNL, Hct WNL. Serum electrolytes WNL. Glucose WNL.

 

Diet instructions:  Diabetic diet

 

Activity: Walking for 10 minute BID. Amputation site dressing changes BID. Shower ok. Pt has been instructed to watch for any fever, purulent drainage, bleeding.

 

Medications:

Anticoagulant

Oral diabetic medications

Diuretic

Tylenol for pain

BetaBlocker

Nitroglycerin for angina

 

FU:  Follow up with Vascular Surgery in 1 week.  Follow up with cardiology in 2 weeks. Return to HMO physician within 1 week for postoperative check up.

 

Discharge condition: Stable and improving.