April 17, 2008
HPI 78 year old internist complains of 10 days of tingling and discomfort in left toes Unable to walk or sleep due to severe pain Pain worse with movement Redness in left toes Bilateral thigh discomfort Began a course of ciprofloxacin taken intermittently 10 days prior to admission
Past Medical History CAD Diabetes Hyperlipidemia Chronic Kidney Disease (creatinine 2.5) Peripheral Arterial Disease (s/p right femoral-popliteal bypass graft in 1996) BPH Gout
Social History Retired internist 2 scotches a day 50 pack-year history, stopped in 2005
Medications Allopurinol ASA Atenolol Colchicine Glyburide HCTZ Lipitor MVI Norvasc Plavix Terazosin Metformin Ciprofloxacin
Physical Exam VSS HEENT: Normal RESP: CTA B CV: RRR, no murmur ABDOMEN: +BS, nt, nd EXT: no edema, right side has dependent rubor, eschar between 2 nd and 3 rd toe. Right: popliteal 0, posterior tibial 1+, dorsalis pedis 0 Left: popliteal 0, posterior tibial 0, dorsalis pedis 0
Imaging: MRI MRI: occlusion of the distal left superficial femoral artery above the popliteal space
Imaging: US and Angiogram Duplex ultrasound: aneurysm of the left popliteal artery with thrombosis and collateral reconstitution on the infragenicular popliteal artery Angiogram: fem-pop bypass graft on the right side. Left popliteal artery thrombosed popliteal aneurysm. Posterior tibial artery is occluded with collateral reconstitution of the lateral tarsal branch of the posterior tibial artery. Peroneal artery is occluded in the midportion and the anterior tibial artery is occluded in the proximal portion
Follow-up Hospital day #4 underwent left in-situ saphenous vein femoral below the knee popliteal artery bypass
Robert Haung, MD 4/17/2008
61 yo man with cold numb foot CC- right cold numb foot. MMP 1. CAD s/p MI, 2 vessel CABG 1992 2. Hyperlipidemia 3. Hypertension 4. Diabetes Mellitus Type II 5. Renal Agenesis
HPI 61 yo man acute onset right numb and cold foot. In good health since CABG 1992 Injured right foot two years ago moving furniture, treated with wraps and arch support, done well since Woke up and notice right foot was pale and numb along lateral foot and calf. Went to pcp later that day, noted no pulses
Home Meds aspirin, Byetta, Diovan, fish oil, Glipizide, Metformin, Metoprolol, Tricor, and Zetia EXAM 142/79 77 98.1F 22 96% RA Cor rrr, s1s2 nl, no murmurs, no palpable pulses right foot Resp - CTA Abd - normal Neuro normal motor exam throughout, slightly decreased sensation to light touch right lateral foot Skin right foot pale, cool to touch, slow cap refill
Labs Cr 1.2
Assessment/Plan Critical limb Ischemia DDX progressive chronic PVD, PVD with plaque rupture, distal emboli Heparin IV therapeutic protocol MRA right leg Vascular and IR consult IVFs Hold Metformin Cont aspirin and cholesterol meds
IR consult Pt did not tolerate MRA Sensation and motor intact Leg warm to level of ankle Cool over top and distal foot CFA and Popliteal artery palp Limb NOT threatened at this pain Heparin IV CTA/US in am
Day 2 Vascular consult Substantial right first toe ischemia Standard angiogram +/- TPA Pelvic and right lower ext arteriogram Widely patent iliac arterial system Normal caliber right CFA, CFA, Pop, and trifurcation Three vessel runoff to distaf calf, then distal emboli to PT and AT at ankle Not a candidate for catheter directed lysis
Day 3 Foot feels warmer since admit Coumadin Lovenox bridge Cont aspirin 81mg daily D/c home
Post hospital course Outpatient vascular medicine consult Waxing/waning course since discharge Protein C 40% Factor V homozygous normal Factor II Gene Mutation homozygous normal Antithrombin III 111% Anticardiolipin aby neg Lupus Anticoagulant not detected
Vascular medicine consult cont. ESR 17 ANA neg Cryoglobulin neg Cold agglutinin <1:64 ANCA neg
TTE, EKG, Holter, Ophtho exam Arterial US right leg/foot Normal resting ankle brachial index bilateral Right toe brachial index mod low 0.48 CT angio chest/abd/pelvis No potential source of emboli found TEE Small PFO, trivial fix atheromatous disease descending aorta