Cliff's possible amputation

HISTORY OF PRESENT ILLNESS: The patient is a 58 year old white male who stepped on a nail approximately two to four weeks prior to 04-08-97.

The patient began having increased pain, redness, and warmth at the site. Secondary to the patient's peripheral neuropathy and inability to feel, the wound had increased in size and gotten infected.

The patient was admitted for observation and surgical intervention of the left lower extremity infection.

HOSPITAL COURSE: On date of admission, it was noted that the patient had electrocardiogram changes consistent with ischemic changes of the heart.

The patient did undergo local incision and drainage of the left lower extremity infection and was taken to the Surgical Intensive Care Unit postoperatively Swan'd and monitored very closely. The patient's fluid status was adjusted while in the Surgical Intensive Care Unit and cardiac workup was initiated. The patient was started on intravenous antibiotics secondary to the left lower extremity infection. The patient was stabilized in the Surgical Intensive Care Unit. He was transferred to the regular floor and cardiac catheterization was undertaken.

The cardiac catheterization revealed a 40 to 50% stenosis in the left main, a 60% stenosis in the mid left anterior descending, a subtotal occlusion in the mid right coronary artery, and two totally occluded marginal branches.

The patient's left ventricular ejection fraction was noted to be 61% by multiple gated acquisition scan. Secondary to the patient's coronary lesion, the patient was offered, surgical intervention which the patient denied and decided to be treated medically.

The patient was then started upon discharge on Lisinopril and Isordil and remained on Atenolol.

For the left lower extremity foot infection, the patient will remain receiving twice a day dressing changes Home Healthcare. The patient will followup in clinic with the Surgery I Clinic next week and additionally will be followed up by Cardiology.

4. Cimetidine 400 mg p.o. b.i.d.

5. Glyburide 10 mg p.o.b.i.d. - .

6. Percocet 1-2 p.o. q4-6h. p.r.n. pain.

DISPOSITION AND FOLLOW-UP: Disposition will be to home with the assistance of Home Health Care for b.i.d. dressing changes and follow-up will be with Surgery Clinic on 07-03-97.

ACTIVITY LIMITATIONS: The patient may walk on foot as tolerated. He is to perform twice daily dressing changes with 1/4 strength Dakin solution with the assistance of home nursing and he may shower with his dressing off.

HISTORY OF PRESENT ILLNESS: The patient is a 57 year old gentleman with non-Insulin dependent diabetes, who stepped on a nail in early June. The nail lodged in his left heel and was removed by the patient. Over subsequent weeks he has had no enlarging ulcer in that area. Prior to admission, he was status post a prior debridement in early June but infection has continued to persist and spread. He denies any systemic symptoms of infection such as fevers, chills, nausea or vomiting.

PAST MEDICAL HISTORY: Other significant past medical history includes non-Insulin dependent diabetes mellitus with diabetic neuropathy and hypertension.

HOSPITAL COURSE: The patient was admitted via Same Day Surgery on 06-18-97. After placement of an ankle block by Anesthesia, he was taken to the operating room where he underwent wound irrigation and debridement of his left foot. Introperative findings included necrotic plantar fascia over calcaneous. This was debrided back to viable margins. The outer table of the calcaneous was debrided with a bur. The wound was irrigated with 3 liters of normal saline via Pulsavac. The patient tolerated the procedure well and there were no apparent complications. After a brief stay in the Postanesthesia Care Unit, he was transferred to 5 South for the remainder of his hospital course.

While on 5 South, he was administered p.o. Cipro, daily whirlpool and q. shift dressing changes with normal saline. Two days postoperatively, recurrence of necrotic tissue was noted in the foot wound. At this point he was switched to 1/4 strength Dakins solution. We continued to examine his foot daily and noted progressive development of necrotic tissue over his bony surfaces and posterior aspects of his foot. During this time, he did remain afebrile with normal white counts. He was kept until 06-27-97 to closely observe the foot.

Prior to discharge, a long discussion occurred between the patient. Dr. Molloy and Dr. Tsuei regarding the prognosis for the patient's foot. At this point, the patient plans to consider his options including a possible amputation below the knee. He does not want to pursue this option during this hospital admission but wishes to go home and think about it. We will discharge him home with b.i.d. Dakin wet to dry dressing changes and he will return to clinic on 07-03-97 for re-examination of the foot and discussion of options at that point. He is to have LEA's prior to discharge today since his last set was in 1994. The results of those LEA's are unavailable at this point. He will also be discharged on his routine medications in addition to Ciprofloxacin 500 mg b.i.d.

MARK MOLLOY, M.D.

Dictated by: Job#: 4236 T: 06-28-97

/s/ MARK MOLLOY

M.D.

Signed: 09/12/1997 00:00

Marked signed on chart by:

for

/s/ MARK MOLLOY

M.D.

Cosigned: 09/12/1997 00:00

Marked cosigned on chart by:

for