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Last Update: 09/24/2023 08:18 AM
Current Deck: Clinical Questions (Vascular)
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Commit #18617
You are in the outpatient clinic and see a new patient – a 72 year old gentleman who has been referred by his GP with left calf claudication.
He has cancelled and rebooked his appointments twice since his wife is currently undergoing palliative chemotherapy for a malignancy, and it has been 9 months since his initial referral.
He states that he came in today because he has been unable to walk more than 10m, and has been getting some pain in his foot at night. This has worsened over the past 2 months. He has also traumatised his left great toe recently, and the wound has not healed. He is a current smoker, and states given his wife’s current health issues he cannot bring himself to give up. He has a background of insulin-dependent Type 2 diabetes, hypertension, obstructive sleep apnoea, and obesity. He has had a previous tonsillectomy, and laparoscopic fundoplication for reflux disease.
On examination, he has an ejection systolic murmur radiating to his carotids, a clear chest, and a soft abdomen with no palpable masses. He has a palpable right femoral pulse, but nothing distal to this in that leg. On the left, he has no lower limb pulses at all. You also note he has a fungal rash in his groins bilaterally, and overhanging abdominal pannus. He has ischaemic rubor to his left foot, and a malodorous sloughy wound to his medial great toe without evidence of associated cellulitis. The wound does not probe to bone. Buerger’s test is positive.
What further management would you recommend for this patient?
Present his case and your recommendations to the interviewer as though they are the consultant for the clinic.
He has cancelled and rebooked his appointments twice since his wife is currently undergoing palliative chemotherapy for a malignancy, and it has been 9 months since his initial referral.
He states that he came in today because he has been unable to walk more than 10m, and has been getting some pain in his foot at night. This has worsened over the past 2 months. He has also traumatised his left great toe recently, and the wound has not healed. He is a current smoker, and states given his wife’s current health issues he cannot bring himself to give up. He has a background of insulin-dependent Type 2 diabetes, hypertension, obstructive sleep apnoea, and obesity. He has had a previous tonsillectomy, and laparoscopic fundoplication for reflux disease.
On examination, he has an ejection systolic murmur radiating to his carotids, a clear chest, and a soft abdomen with no palpable masses. He has a palpable right femoral pulse, but nothing distal to this in that leg. On the left, he has no lower limb pulses at all. You also note he has a fungal rash in his groins bilaterally, and overhanging abdominal pannus. He has ischaemic rubor to his left foot, and a malodorous sloughy wound to his medial great toe without evidence of associated cellulitis. The wound does not probe to bone. Buerger’s test is positive.
What further management would you recommend for this patient?
Present his case and your recommendations to the interviewer as though they are the consultant for the clinic.