HPI & HISTORY

HPI:
48 y/o legally blind Spanish-speaking female w/ hx of NIDDM, DR, ESRD on HD w/ associated chronic anemia,
HTN, and PAD s/p LLE pop-tib bypass (12/2014) presenting with complaints of generalized weakness in all 4
extremities for several days.
History limited by somnolence and incomplete answering of some questions. Reports having missed prior HD
session and feeling weak thereafter.
Multiple episodes non-bloody diarrhea up to 4x daily x 1 week. Denied travel, sick contacts, recent
hospitalizations, antibiotics, fever/chills.
Patient noted yellowing of skin and eyes recently, but has no known hx of liver disease. Reports prior heavy
alcohol use of unspecifiable quantity and duration, though abstinent for many years now. Denied abdominal
pain, nausea, vomiting.
Chronic bilateral lower extremity swelling unchanged from baseline
PMHx: Nothing else significant
PSHx: Multiple LLE Vascular Surgeries:
(12/30/14) Left popliteal-to-posterior tibial reverse saphenous vein bypass with PT endarterectomy, left
saphenous vein harvest
(1/5/15) Amputation of left first and second toe
(2/20/15) Transmetatarsal amputation
(3/3/15): Angiogram and Angioplasty of bypass graft anastomosis stenosis
Meds: nothing unusual given chronic medical conditions
Allergies: Multiple antibiotics allergies (Zosyn, Cefepime, Flagyl, Daptomycin) with ambiguous reactions
designated as Other or Loose Control

PHYSICAL AND LABS

Vitals:
T: 37.1

HR: 85

Resp: 16

BP: 152/72

SpO2: 99%

Physical Exam:
Gen: somnolent but arousable, ill-appearing
HEENT: NC/AT, dry mucous membranes, +scleral icterus
CV: RRR, no murmurs/gallops/rubs
Pulm: CTAB, poor inspiratory effort, no wheezing/rales/ronchi
Abdm: normal BS, soft, ND/NT, no organomegally
Ext: BL L/E 2+ pitting edema up to knees, L foot stump s/p TMA with open wound that probes to bone and
pasty yellowish discharge, dusky appearance, medial area of fluctuance and visible fluid tracking from below
wide area of blistering, no palpable pulse BL
Skin: slight jaundice, no rash
Neuro: CN II-XII intact, no asterixes
Labs:
Na: 129
BUN 82
Cr: 8.6
LFTs: ALP 321, T bili 7.1, AST/ALT wnl,
INR 1.33
WBC: 31 -> 29
ECG: NSR at 82bpm, no ectopy, normal WT and T waves

ASSESSMENT & PLAN

#PAD h/o LLE critical limb ischemia s/p TMA: foot stump with open wound probing to bone and adjacent area
of fluctuance and fluid tracking concerning for possible osteomyelitis and necrotizing fasciitis. Afebrile, but
leukocytosis. SIRS negative but immunocompromised due to ESRD and may not mount full immune response.
foot xray STAT
consult ACS
wound culture and blood culture
Start empiric osteo tx vancomycin IV 1g x1 and levofloxacin 500mg x1 now (cefepime allergy), renaly dosed
#Diarrhea: given appearance and leukocytosis, suspect c diff
continune Vanc PO (due to flagyl allergy), started in ED
c diff and stool studies
#Elevated Alk-Phos: new scleral icterus, mild jaundice, elevated Alk-phos, INR 1.33 suggesting liver pathology
possibly d/t prior heavy EtOH use. No work-up for elevated Alk-Phos.
f/u abdominal US completed in ED
ammonia level and acute hepatitis panel
#ESRD on HD: missing HD in the last week
Nephro for HD (no urgent HD for now)
cont home ESRD meds
# VTE PPx:
On plavix
# FULL CODE