May 2006         

History:   The patient is a 44-year-old with a past medical history significant for hypertension, bipolar disorder as well as alcohol dependency, who originally presented to the emergency room on March 27, 2006, with the complaints of chest pain as well as blue toes. The patient states he had a several day history of chest pain that is described as a dull, substernal chest pain with radiation to his left arm that had been present for several days prior to presentation. He notes no prior history of this and has taken no previous medications. He states that he had quit drinking for nine months in the past year but starting about six months ago had been drinking again. He initially started off with a six pack of beer but at the time of admission had been drinking nearly a 12 pack of beer per day as well as a fifth of vodka. The patient also notes a greater than 30 pack year history of tobacco use with no recent attempts at quitting.

During the March hospital stay the patient was evaluated with a nuclear medicine stress test and subsequent cardiac catherization which revealed reversible ischemia and 3-vessel disease.  During his hospitalization he experienced severe agitation and tremors due to alcohol withdrawal.   Because of his significant coronary artery disease the patient was evaluated by surgery and based on their recommendations and due to the patient's history of alcohol abuse as well as smoking, it was felt
that the patient would be a candidate for bypass surgery however it was recommended that he attend an inpatient alcohol detoxification program prior to undergoing bypass surgery.

Vascular Evaluation: He did have 2+ radial pulses bilaterally. He also had 2+ femoral pulses and 1+ popliteal pulses. He did have palpable pulses in both dorsalis pedis and posterior tibial. His extremities were warm to the touch. There are no ulcers or lesions. The toes appeared normal. He had an abrasion at the distal end of his right 1st toe.  This did not appear infected. There is no evidence of infection.
There was healthy tissue surrounding this.  Doppler ultrasound was normal.

May 22, 2006:  He presents today with a left great toe ulcer. It has been there almost one and a half months, and now is down to the bone. He stabbed his toe, but does not remember how. Orthopedics has not seen yet secondary to coronary artery disease. He has been on two week Keflex as an outpatient, which has failed.

ADMISSION DIAGNOSES:  Toe infection, rule out osteomyelitis.

PROCEDURE(S):
1. Triple phase bone scan.
2. MRI bilateral lateral extremities.
3. Bilateral lower extremities arterial Dopplers.
4. CT angiogram.
5. PICC placement.

FAMILY HISTORY:
Dad had myocardial infarction at age 38, mom with myocardial infarction status post CT surgery at the age 60 years.

SOCIAL HISTORY:  Past alcohol abuse, quit smoking one month ago, previous history of 30
pack year smoking.

PHYSICAL EXAMINATION:
EXTREMITIES: No cyanosis, clubbing, or edema. Decreased sensation bilaterally. Left great toe with 2.5 cm round ulcer at the tip of the toe with probe to the bone.

LABORATORY DATA:  On presentation, WBC 11.8

HOSPITAL COURSE:
The patient was admitted to Team 3A for further evaluation of his left great toe ulcer. Was started on vancomycin and Zosyn empirically after drawing the wound cultures and blood cultures. Wound cultures
have grown methicillin sensitive Staph. aureus. The patient has been afebrile during the hospitalization, and blood cultures were negative.  Triple space bone scan was done to evaluate for possible osteomyelitis, which was significant with multiple spots of osteomyelitis.

Orthopedics was consulted, and have evaluated the patient. Recommended to have Vascular Surgery evaluation for possible ischemic etiology, and Vascular Surgery has seen the patient. They recommended to have lower extremity arterial Doppler with ABIs, which was normal, as patient has ulcers on different toes. They recommended having CT angiogram by Interventional Radiology for further evaluation of possible peripheral vascular disease. CT angiogram was done, which was not significant for any significant peripheral vascular disease, as there were no significant blockages, Vascular Surgery did not think that he could do any procedures on him, and hence Orthopedics was consulted again. MRI of the lower extremities was done. MRI showed left great toe osteomyelitis and multiple bone infarcts bilateral lower extremities.

Radiology Report:  THREE PHASE BONE SCAN AND WHOLE BODY IMAGING
05/22/06

PROCEDURE: Three phase bone scanning of the feet was performed using 31.8mCi Tc 99m MDP. Spot imaging and whole body imaging of the feet was performed at the delayed study.

FINDINGS: The blood pool is increased to the left foot and left first toe. The blood pool study shows increased activity in the blood pool of the left first toe, base of the second or third left metatarsal, and the entire heel on the left as well as the lateral midfoot on the right. Delayed imaging shows the activity as described above. Increased activity in the left first toe, base of the left second or third metatarsal and also increased activity throughout the entire calcaneus as well as the distal left tibial metaphysis. The right side activity is noted in the fifth metatarsal and extends about two-thirds up to the MTP joint.

IMPRESSION: THIS IS CONSISTENT WITH OSTEOMYELITIS OF NUMEROUS PLACES IN THE PATIENT'S FEET. THE FIRST TOE, THE BASE OF THE SECOND OR THIRD METATARSAL, LEFT CALCANEUS, AND RIGHT FIFTH METATARSAL. CLINICAL CORRELATION AND/OR MRI MAY BE USEFUL HERE.

The Orthopedic Trauma Team was consulted for possible amputation of this toe. We discussed with the patient the surgical risks and nonsurgical options including IV antibiotics and local wound care. We did advise the patient that this would be unlikely to eradicate the infection from the bone, therefore he elected for surgical amputation of a portion of the left great toe.  Ortho took him to surgery and have amputated left great toe, and have recommended Vascular to see the patient again for possible vascularity.

DISCHARGE FOLLOW UP:
1. With PCP in one week.
2. With psychiatric doctor for his bipolar disorder as scheduled.
3. With Orthopedics in two weeks for follow up of the amputation of the left great toe.
4. Vascular Surgery for evaluation of wound infection, and possible vascular etiology.
5. CT surgery for coronary artery bypass grafting surgery.