Follow-Up Consult (Vascular Surgery)

PATIENT John Smith DATE OF CONSULTATION 1 November 2024 PLACE OF CONSULTATION Rooms, 123 Vascular Clinic, London PROBLEM LIST 68-year-old male * Chronic limb ischaemia, right leg * Rutherford class 3 * Peripheral arterial disease, multilevel * Previous right femoropopliteal bypass (2022) * Right common iliac artery 80% stenosis * Type 2 Diabetes Mellitus * Insulin dependent, suboptimal control (HbA1c 8.5%) * Diabetic neuropathy, mild * No evidence of retinopathy or nephropathy * Hypertension * Controlled on 2 antihypertensive agents (ramipril, amlodipine) * Left ventricular hypertrophy, mild * Hyperlipidaemia * On statin therapy NEW CONCERNS/COMPLAINTS Patient reports increased claudication distance to 50 meters, previously 100 meters, right calf pain. CLINICAL EXAMINATION Right leg: Cool to touch below knee. Absent popliteal, dorsalis pedis, and posterior tibial pulses. Capillary refill time >3 seconds. No trophic changes. No ulceration. Left leg: WNL. SPECIAL INVESTIGATIONS Laboratory Results * HbA1c: 8.5% (previous 7.9%) * Creatinine: 98 µmol/L (stable) * eGFR: 65 mL/min/1.73m² Imaging Studies * Duplex Ultrasound, Right Leg Arteries (1 November 2024): Significant flow reduction in right common iliac artery, consistent with known 80% stenosis. Patent femoropopliteal bypass graft with good flow. ASSESSMENT 68-year-old male * Chronic limb ischaemia, right leg * Worsening claudication, Rutherford class 3 * Critical right common iliac artery stenosis (80%) * Patent femoropopliteal bypass graft * Type 2 Diabetes Mellitus * Insulin dependent, suboptimal control (HbA1c 8.5%) * Diabetic neuropathy, mild * Hypertension * Controlled on 2 antihypertensive agents * Left ventricular hypertrophy, mild * Hyperlipidaemia * On statin therapy PLAN * Investigations planned * CT angiogram aorta and bilateral lower limb arteries * Referral for formal treadmill test * Treatments planned * Optimise diabetic control: Liaise with endocrinology, consider insulin regimen adjustment * Continue current antihypertensive and statin therapy * Referrals * Endocrinologist for diabetes management * Lifestyle recommendations * Supervised exercise programme * Smoking cessation reinforcement TTO Nil FOLLOW-UP DATE 1 February 2025 DOCTORS TO BE COPIED IN Dr Sarah Lee (GP), Dr Mark Jones (Endocrinologist) Comments Patient educated on importance of diabetes control and smoking cessation. Discussed risks and benefits of potential revascularisation procedures.