Initial Consult (Vascular Surgery)

PATIENT John Smith DATE OF CONSULTATION 1 November 2024 PLACE OF CONSULTATION Consulting Rooms, 123 Vascular Clinic, London REFERRAL Referring Doctor Dr. Sarah Jones Referral Diagnosis Left lower limb claudication General Practitioner (if not referring doctor) Dr. Michael Green HISTORY Main Complaint Left calf pain on walking, relieved by rest, progressive worsening over 6 months Pain onset insidious 6 months ago, constant ache when walking >100m, resolves with 5 min rest. Severity 6/10 on exertion Pain localised to left calf, crampy quality, severe on inclines Relieved by rest, exacerbated by walking, no self-treatment attempts effective Symptoms gradually worsened, walking distance reduced from 500m to 100m No previous episodes of similar symptoms Impacts daily walks, unable to participate in usual activities No associated focal or systemic symptoms Past Medical History Hypertension, hypercholesterolaemia Other Past Medical History Nil Chronic Medication 1. Amlodipine 5mg OD 2. Atorvastatin 20mg OD Allergies Penicillin (rash) Past Surgical History None Social History Smoking habits Smokes 10 cigarettes/day, 30 pack years Alcohol drinking habits Drinks beer, 3-4 units/week, occasional binge drinking Other Social History Retired builder, pensioner Family History Father had myocardial infarction at 55, paternal uncle had peripheral arterial disease Systemic Enquiry CNS - Nil history of stroke, TIA, amaurosis fugax CVS - Nil history of MI, angina, orthopnoea, PND, dyspnoea, sleeps on 1 pillow GIT - Nil history of unexplained weight loss, post-prandial pain, loss of appetite CLINICAL EXAMINATION General Examination No jaundice, no pallor, no cyanosis, no clubbing, no oedema, no lymphadenopathy Other General Examination Findings Well-nourished, alert, cooperative Vital Signs BP 145/88 mmHg right arm, 140/85 mmHg left arm; HR 72 bpm regular; O2 Sat 98% room air; Temp 36.8°C Vascular System Inspection: Left lower limb skin pale on elevation, rubor on dependency. No ulceration. Right lower limb normal Palpation: Carotid pulses normal, radial pulses normal, femoral pulses normal, popliteal pulse absent left, dorsalis pedis pulse absent left, posterior tibial pulse absent left. All pulses palpable on right lower limb Capillary refill: >3 seconds left foot, <2 seconds right foot Bruits: Femoral bruits bilaterally, no carotid bruits Respiratory System Clear breath sounds bilaterally, no added sounds Cardiovascular System S1 S2 heard, no murmurs, JVP not elevated Gastrointestinal System Soft, non-tender abdomen, no masses, no hepatosplenomegaly, no abdominal bruits. No AAA detected on palpation Central Nervous System Intact GCS, no focal neurological deficits Urogynaecological System Not examined Other Nil SPECIAL INVESTIGATIONS Laboratory Results Full blood count normal. Urea and electrolytes normal. Fasting lipids: Total cholesterol 5.8 mmol/L, LDL 3.5 mmol/L, HDL 1.1 mmol/L, Triglycerides 1.9 mmol/L. HbA1c 5.9%. Imaging Studies Duplex ultrasound left lower limb: Significant stenoses in superficial femoral artery and popliteal artery Other ECG: Normal sinus rhythm ASSESSMENT 68-year-old male * Peripheral Arterial Disease (Left lower limb) * Fontaine Stage IIa claudication * Significant stenoses SFA and popliteal artery on duplex * Hypertension (controlled with single agent) * Hypercholesterolaemia (poorly controlled on Atorvastatin) * History of smoking (30 pack years) * Family history of cardiovascular disease PLAN * Continue Amlodipine 5mg OD * Increase Atorvastatin to 40mg OD * Prescribe Aspirin 75mg OD * Discuss smoking cessation strategies, offer referral to smoking cessation clinic * Discuss regular supervised exercise programme * Arrange CT Angiogram left lower limb for surgical planning * Refer to Vascular MDT for further management discussion * Patient education on disease progression and lifestyle modification TTO Nil FOLLOW-UP DATE 4 weeks Comments Patient educated on peripheral arterial disease, importance of smoking cessation, and medication adherence. Concerns regarding potential surgical intervention addressed. DOCTORS TO COPY IN Dr. Sarah Jones, Dr. Michael Green