DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Dysvascular second toe, left foot.
HISTORY OF PRESENT ILLNESS: The patient states that over the last three weeks, she has developed pain and discomfort involving the left foot. The second toe has become discolored and slowly progressed and worsened. The patient was sent to the emergency department last evening and admitted due to dysvascular changes.
PAST MEDICAL HISTORY: Insulin-dependent diabetes mellitus, hypertension, coronary artery disease, and history of severe peripheral vascular disease. She has had previous hypoglycemia events as well as chest pain workup. The patient had previously refused a cardiac catheterization.
MEDICATIONS: Metoprolol, Isordil, Zestril, Catapres, Celexa, Norvasc, and insulin.
PAST SURGICAL HISTORY: The patient denies.
SOCIAL HISTORY: The patient denies alcohol use or abuse or smoking.
FAMILY HISTORY: Noncontributory.
ALLERGIES: NKDA.
PHYSICAL EXAMINATION: Currently finds the patient in a stable condition. Vital signs are stable. The patient is afebrile. Temperature 98.2 degrees, blood sugar 130. Vascular examination finds the dorsalis pedis and posterior tibial pulses on the left lower extremity nonpalpable. There may be a trace palpable dorsalis pedis; however, this is not easily palpated. Local temperature is warm to cool. Neurologic examination reveals sensorium deficits, likely due to the patient’s history of diabetes mellitus. Dermatologic examination reveals dark and dysvascular necrotic changes to the distal aspect of the second toe in the left foot. This appears to be focalized and local to the second toe only. No ascending erythema. No purulent discharge is seen at this time. Skin is shiny and taut. Hair growth is diminished. Adequate muscle strength noted. Orthopedic exam shows no sign of fracture, subluxation or dislocation.
ASSESSMENT:
1. Insulin-dependent diabetes mellitus with neuropathy.
2. Severe peripheral vascular disease.
3. Necrotic changes, second toe, left foot.
PLAN: We have recommended initiation of vascular assistance. We have asked further assistance of Dr. Jane Doe. We have ordered an MRI to rule out osteomyelitic changes. We believe this to be possibly focalized and localized to the toe only. The patient may require a second toe amputation; however, healing ability may be compromised given the patient’s history of peripheral vascular disease. We will currently await the impression from Dr. Jane Doe. Antibiotics as per Internal Medicine and/or Infectious Disease. Dressing change orders provided.
