ysical report Reason for Admission: Severe, short-distance, lifestyle-limiting right lower extremity claudication Histor

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Ysical Report Reason For Admission Severe Short Distance Lifestyle Limiting Right Lower Extremity Claudication Histor 1 (85.51 KiB) Viewed 34 times

ysical report Reason for Admission: Severe, short-distance, lifestyle-limiting right lower extremity claudication History of Present iness: This is a 32-year-old woman who developed new-onset right lower extremt dication following right transfemoral cardiac catheterization for routine follow-up 10 years after cardiac tran plantation. The catheterization was approximately 10 days ago. Since that time, she describes symptoms of pain in her calf after walking approximately 20 yards or less. If she walks too far, she develops paresthesie complete numbness in the right foot. The pain is relieved by rest. She does not have rest pain at night. She has never had any symptoms similar to this or any symptoms in the contralateral leg She underwent cardiac transplantation 10 years ago. Since that time, she has had annual routine evaluation by transfemoral cardiac catheterization. Dr. Smith, who reviewed the films from the catheterization, reports that there is evidence of mild narrowing in the common femoral artery, possibly due to prior catheterizations. There is also some concern regarding the possibility of arterial dissection more proximally, although this may be an artifact on the anglogram. Allergies: No known drug allergies Past Medical History: (1) History of hypertrophic cardiomyopathy, now status post cardiac transplantation. (2) Intermittent episodes of rejection (3) History of herpes zoster. Past Surgical History: Cardiac transplantation Medications: Pepcid 20 mg po bid, Vasotec 5 mg po bid, magnesium oxide 400 mg po bid, aspirin 81 mg po bid, CellCept 1 gm po bid, Neoral 100 mg qam and 75 mg qpm Social History: The patient is a schoolteacher. Habits: She drinks alcohol occasionally and does not smoke cigarettes Review of Systems: The patient has no active cardiopulmonary symptoms of which she is aware and no history of hepatorenal dysfunction. She has had no other episodes of bleeding or thrombotic disorders. Physical Examination: HEENT: Unremarkable CHEST: Clear throughout to auscultation Regular rhythm without murmur, gallop, or rub CARDIOVASCULAR: ABDOMEN: Soft, nontender with no obvious masses or organomegaly Deferred GENITALIA/RECTAL: EXTREMITIES: No clubbing, cyanosis, or edema. There is no dependent rub or pallor on eleva- tion. The patient has normal sensation and motor function in the lower extremi- ties. Pulses are 3/3 except in the right lower extremity, where no palpable pulses are present. Potassium 3.8; hematocrit 45; sodium 142 LABORATORY DATA: TEST RESULTS: Angiography demonstrated occlusion of the external liac artery from near the bifurcation to the distal common femoral artery, which reconstitutes just above its own bifurcation. A guide wire passed easily through this, suggesting soft throm- bus. There is excellent collateralization and no evidence of distal abnormalities. Duplex ultrasonography performed earlier demonstrated no evidence of deep or superficial thrombophlebitis. Noninvasive vascular studies also suggested aortolliac/femoral occlusive disease with good collateralization distally. Impression: 1. Occluded right external iliac and common femoral artery following transfemoral cardiac catheterization 2. Status post cardiac transplantation for hypertrophic cardiomyopathy 3. History of herpes zoster Plan: The patient will be admitted to the hospital to undergo operative intervention to repair the femoral artery injury. Several possibilities exist, including possible dissection of the artery and injury to the artery during the catheterization or development of a collagen plug post angiography. I have discussed these possibilities with the patient, and I plan to perform an exploration of the right femoral area and, if necessary, a right lower quadrant, retroperitoneal incision to expose the proximal bifurcation and a bypass if necessary. Discussed the possibility of vein patch angioplasty as well. We also discussed the risks of the operation including MI, CVA, death, infec- tion, bleeding, nerve injury, embolization and tissue loss, bowel injury, etc. She understands all these things as well as the indications for operative intervention. We plan to operate tonight as soon as an operating room is available.