Vascular Case: 72-year-old Man with Foot Pain and Gangrenous Left Hallux

00:01 A 72-year-old man is admitted to the cardiology service because of severe foot pain and a gangrenous left hallux.

00:08 His personal history shows that he's had type 2 diabetes for at least 20 years, hyperlipidemia, with the elevated cholesterol and hypertension none of which have been treated.

00:20 He's not been someone who goes to the doctor.

00:22 He smokes one pack of cigarettes per day and has done so since age 22.

00:27 On physical exam he’s obese. His blood pressure is 165/72, his heart rate is 78.

00:34 His peripheral oxygen saturation is normal at 92% and he has normal jugular venous pressure.

00:39 He has an early systolic ejection murmur heard best at the upper right sternal border consistent with aortic sclerosis, in other words early atherosclerosis and calcification of the aortic valve.

00:52 That murmur would sounds like this, first normal, lub-dub, lub-dub.

00:56 Now with the murmur, lub-shshdub, lub-shshdub, lub-shshdub.

01:02 This is not aortic stenosis yet but is a process that leads eventually to aortic stenosis if the patient lives long enough.

01:08 Femoral pulses are weak, dorsalis pedis pulse in the food is not felt bilaterally and the left hallux is gangrenous.

01:17 The laboratory shows a number of abnormalities.

01:21 The fasting blood glucose is 208 mg%, hemoglobin A1C is 10.4 mg%, creatinine 1.9% showing that the patient already has renal insufficiency and his lipids are markedly abnormal total cholesterol 298, HDL low at 29, LDL high at 201 and triglycerides high at 505.

01:45 So the critical things in this history first of all severe left pain in the left big toe with evident gangrene, we're gonna show you a picture of that.

01:59 A long history of diabetes mellitus and cigarette smoking, hypercholesterolemia, none of which has been taken care of and that puts him at a very high risk for atherosclerotic heart disease.

02:11 And we see on exam he’s hypertensive, he’s oxygen saturation’s okay but he already has a evidence of atherosclerosis in the aortic valve and his peripheral vascular situation is not good with poor pulses felt as well as gangrene.

02:28 So again the laboratory, abnormal glucose, very abnormal hemoglobin A1C - The newer age hemoglobin A1 C therapeutic targets indicate a goal at least 7.5 or lower in this patients We prefer to see them down in the lower sixes, in fact.

02:47 This patient also has a glomerular filtration rate of 38, which indicates stage three B chronic kidney disease.

02:55 Again, almost certainly due to his diabetes, so-called Kim or Steele Wilson disease.

03:01 So here we see a picture of his other toe from above and below.

03:06 You can see evident gangrene on his foot and that’s because of poor perfusion with blood flow.

03:14 The necrotic tissue can’t be salvaged but gradually if the patient gets good care, that tissue will die off and new skin will grow underneath but poor care will result in amputation of at least the forefoot depending on the blood supply if not below the knee amputation.

03:34 The diagnosis arteriosclerotic peripheral vascular disease with gangrene of the left big toe, diabetes mellitus type 2, poorly controlled; hyperlipidemia, not controlled; hypertension, not controlled; renal insufficiency probably the result of diagnosis 2, 3, and 4 and exogenous obesity.

03:47 Stage 3 chronic kidney disease with a GFR of 38.

03:51 Most likely it relates to the fact that his diabetes has not been well Most likely it relates to the fact that his diabetes has not been well treated as well as his hypertension and has not been well treated.

03:59 And both of these are exacerbated, of course, by his exogenous obesity.

04:04 So what’s the management if the patient is willing to participate? I always tell patients working on your disease is a 50% partnership for each of us.

04:15 You’d have to do your thing and I get to do my thing and together we can help you.

04:20 So patients have to make that decision, they don’t want to get treated then of course we know the outcomes are not good.

04:27 Management consist of intense medical counseling about health conditions and options for treatment and medications for type 2 diabetes probably metformin.

04:35 Hypertension almost certainly amlodipine, one has to be a little careful with the ACE inhibitor Lisinopril because it can worsen renal insufficiency.

04:45 I'm usually willing to try it in somebody whose creatinine is less than two and he’s right in that zone so one might use Lisinopril.

04:52 Lisinopril and other ACE inhibitors had been demonstrated to decrease the progression of renal insufficiency in patients with diabetes so you’d like to do that.

05:01 Hyperlipidemia, a statin, for example atorvastatin needs a cardiac rehab referral to keep reinforcing the lessons we’re giving him and of course we had to tell him that smoking will cause a tremendous likelihood that he’s gonna loss that foot or even that leg.

05:17 He needs to stop smoking and we can help with that and finally diet exercise and lifestyle modifications.

05:25 This patient should have consultations with the podiatrist and a vascular surgeon.

05:30 Podiatry can help with diabetic foot care and help prevent infections.

05:36 And he might of course, need a toe amputation for the toe that's already involved.

05:41 If you recall from this patient's physical exam, he had weak femoral pulses and absent bilateral dorsalis Peters pulses.

05:49 So vascular surgery consultation would be a good idea for further evaluation for possible treatment.

05:56 For example, angioplasty or even surgery to improve blood flow to his legs.