Note from James Barry, MD at 1991-10-13 04:00

History of Present Illness: The patient is a 74-year-old diabetic white male who presents with a four month history of nonhealing ulcerative lesion over the right lateral malleolus.  He underwent a partial right foot amputation in 1985 for vascular disease and had no complications until this recent lesion.  His wife feels that it may have started from trauma to the foot but the patient is unsure since he lacks adequate sensation in the area due to obvious diabetic neuropathy.  He denies claudication or foot and leg rest pain bilaterally.  Recently Doppler studies show a right ABI of .44, suggesting moderate arterial obstruction and a left ABI of .78 suggesting mild arterial obstruction.  He is admitted for angiographic studies and possible vascular reconstruciton.

Past Medical History: Surgery- right partial foot amputation 1985, bilateral retinal laser procedures for diabetic retinopathy.  Medical-Glaucoma right eye greater than left times 18 months.  Diabetic retinopathy.  Insulin-dependent diabetes mellitus, 20 years - insulin started 1975.

Allergies: Penicillin which causes skin rash.

Family History: Negative for diabetes mellitus or thyroid disease.  A brother died of emphysema.  A second brother died of a MI and a third brother died of multiple MIs and CV complications.  His mother died of complications of hip fracture.  His father died of atherosclerotic disease and was quite old at the time of death.

Social History: The patient is retired from construction work.  He has smoked 1-2 packs for 55 years and is currently smoking 2-3 packs per day, though he states that he has stopped on this admission.  There is a positive ethyl alcohol history.  He stopped 20 years ago with a diagnosis of diabetes mellitus.

Review of Systems:  HEENT: Glaucoma, diabetic retinopathy.  The patient wears upper and lower dentures.  CV- The patient denies angina, MI, strokes, syncope or claudication.  Respiratory- The patient denies shortness of breath, exertional shortness of breath, PND or hemoptysis.  GI: Adequate diet.  The patient states normal bowel movements with no diarrhea, constipation or hematochezia.  GU: Denies dysuria, but has a positive history of post void dribbling, but no incontinence symptoms.  Extremities: See present illness.  Endocrine: Positive for insulin-dependent diabetes mellitus, negative thyroid disease.

Medications: NU 100 30 units and RU 110 units in the a.m; NU 100 10 unites in the p.m., Timoptic 0.5% one drop b.i.d. right eye, Atropine 1% one drop b.i.d. right eye.  Pred Forte 1% one drop b.i.d. right eye, Neptazane 5mg one tablet q. daily, Halcion q.h.s., ASA q daily, Trental one tablet p.o. The patient and family is unsure of dosage one tablet after each meal. 

Physical Examination: BP 145/56, T 97.1, P 69, R 18, Wi162.  The patient is a cooperative, well-developed, well-nourished, white male in no acute distress.

HEENT: Normocephalic, atraumatic.  TMJ is intact.  There is a sporatic papular rash noted on the forehead and cheeks.  Right eye shows a cloudy cataract with slow pupillary response probably secondary to Atropine drops.  The right lower lid shows evertive laxity and there is lack of total corneal coverage noted on blinking.  The left eye shows pupil being equal and responsive to light.  EOMs are intact.  Fundi are difficult to observe due to cataracts.  Oral mucosa is pink.  Negative dentures are in place.  Uvula and tongue is midline.  There are tobaco stains noted on the lip margins.

Neck: Supple without JVD, carotids are 2/2.  Positive bruit is noted on the left carotid high in the neck.  Trachea is midline.

Lungs: Bilateral breath sounds are positive, but there are faint sounds noted.  There are no distinct rales, rhonchi or wheezes noted on exam.

Heart: RRR with a faint systolic ejection murmur noted at the left sternal border.

Abdomen: Nontender, nondistended without organomegaly, positive bowel sounds.

Extremities: Arms and legs show marked seborrheic keratotic lesion.  There are dark brown tobacco stains noted to the nails of the right hand.  The distal legs are dry, scaley and show mild atrophic appearance to the calves.  Ther eis a well healed amputative site to the right foot.  The right lateral foot shows a discoid ulcerative wet lesion.  

Pulses: Femoral left 2, right 1.  There are no distal pulses palpable distal to the femoral arteries.  There is good capillary refill noted to the left toes.  

Neurological: Alert and oriented times three.  Cranial nerves II-XII are grossly intact.  Grips are 4/4.  Muscle groups are 4/4.  

Impression: 1. Insulin-dependent diabetes mellitus.                                                                                                                 

                  2. Peripheral vascular disease with multilevel obstruction.

                  3. Glaucoma O.U

                  4. Diabetic retinopathy O.U

                  5. Seborrheic keratosis.

                  6. Chronic tobacco abuse.

Plan: Aortic angiography with bi-fem run off in the a.m.  Possible vascular reconstruction surgery on the right leg.  Support diabetes.  Support glaucoma.

Berry James MD,

Attending Physician 

Signed by James Barry, MD at 1991-10-13 04:00