Note from William Tilley, MD at 1991-10-14 05:00

Consultation Report

HISTORY OF PRESENT ILLNESS: Thank you for asking me to see this 74-year-old, white male for cardiac evaluation prior to vascular surgery of the left. The patient has no previous cardiac history. He denies previous history of MI, angina, CHF symptoms or arrythmias. He may have had a small stroke over 25 years ago with mild left hemiparesis. This minimally affected his left hand at the time, so he says. 

He presented with a nonhealing ulcer on his right foot and had toes amputated a while back in 1985. He denied claudication, but has rest pain bilaterally. He had poor arterial Doppler indices on the right and is admitted now for vascular reconstruction.

It is important to note that he has had diabetes mellitus for 20 years and has had insulin for the past 16 years. He has glaucoma and also has known diabetic retinopathy and has had bilteral retinal laser procedures. He has been a heavy smoker and smoked until the time he came in here. He doesn't have hypertension or other serious illnesses.   

PAST MEDICAL HISTORY: MEDICAL: No history of ulcers, hypertension or kidney stones. SURGICAL: Previous surgery: Amputation of toes in 1985. ALLERGIES: PENICILLIN CAUSES A RASH.        CURRENT MEDICATIONS: Insulin. 

FAMILY HISTORY: Positive for MI and atherosclerotic cardiovascular disease.

SOCIAL HISTORY: The patient lives with his wife. He smokes 2-3 packs of cigarettes per day for 55 years. He quit drinking 20 years ago when he was diagnosed as having diabetes. He used to work construction.

REVIEW OF SYSTEMS: He had glaucoma previously and has known diabetic retinopathy. He is relatively inactive. 

PHYSICAL EXAMINATION: He's a pleasant male. BP 140/60, pulse 76, weight 162. SKIN: Warm and dry. He has mild purpuric lesions over the forearms bilaterally and mild acneiform rash over the face. ENT is difficult to visualize. Tobacco stains are present on the lip margins. NECK: Supple, no JVD. There's a high-pitched right carotid bruit and a softer left carotid bruit. LUNGS: Clear. No rhonchi were heard. HEART: Normal S1, S2. There's a I/VI systolic murmur in the aortic area. ABDOMEN: Soft and nontender. Femoral pulses are 2+ on the left, 0-1+ on the right. Distal pulses are not palpable. 

LABORATORY DATA: Twelve-lead EKG shows no specific abnormality. Chest x-ray shows normal heart size. Echocardiogram shows normal heart size, possible mild apical hypokinesis, calcified and thickened aortic valve with adequate opening. 

IMPRESSION: 1. Peripheral vascular disease in need of revascularization.  2. Diabetes mellitus, insulin-dependent, with retinopathy.  3. COPD with chronic cigarette abuse, ongoing. 

RECOMMENDATIONS: The patient has limb jeopardy at the present time and he's in need of a vascular opperation. He doesn't have any adverse symptoms of heart failure or myocardial ischemia, but may well have silent ischemia because of his diabetes. Nevertheless, in view of his lack of symptoms and the need of an operation, I would recommend proceeding with the operation, as planned, without further cardiac work-up. I would suggest that he have perioperative monitoring with Swan-Ganz catheter and arterial line. His overall risk of the operation is somewhat increased due to his age and type of operation planned, but I believe it is acceptable, considering his other problems. 

William S. Tilley, M.D.
Surgery

Signed by William Tilley, MD at 1991-10-14 05:00