A 72-year-old man is admitted to the cardiology service because of severe foot pain and a gangrenous left hallux.
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.
He's not been someone who goes to the doctor.
He smokes one pack of cigarettes per day and has done so since age 22.
On physical exam he’s obese. His blood pressure is 165/72, his heart rate is 78.
His peripheral oxygen saturation is normal at 92% and he has normal jugular venous pressure.
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.
That murmur would sounds like this, first normal, lub-dub, lub-dub.
Now with the murmur, lub-shshdub, lub-shshdub, lub-shshdub.
This is not aortic stenosis yet but is a process that leads eventually to aortic stenosis if the patient lives long enough.
Femoral pulses are weak, dorsalis pedis pulse in the food is not felt bilaterally
and the left hallux is gangrenous.
The laboratory shows a number of abnormalities.
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.
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.
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.
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.
So again the laboratory, abnormal glucose, very abnormal hemoglobin A1C -
we’d like to see that down in the sixes. Renal insufficiency and marked hyperlipidemia.
So here we see a picture of his other toe from above and below.
You can see evident gangrene on his foot and that’s because of poor perfusion with blood flow.
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.
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.
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.
You’d have to do your thing and I get to do my thing and together we can help you.
So patients have to make that decision,
they don’t want to get treated then of course we know the outcomes are not good.
Management consist of intense medical counseling about health conditions
and options for treatment and medications for type 2 diabetes probably metformin.
Hypertension almost certainly amlodipine, one has to be a little careful
with the ACE inhibitor Lisinopril because it can worsen renal insufficiency.
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.
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.
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.
He needs to stop smoking and we can help with that and finally diet exercise and lifestyle modifications.