Chief Diagnosis: Right trans-metatarsal amputation

1. This has caused damage to the blood vessels and helped cause constriction. Smoking also increases blood pressure, which in turn increases the chance of a clot forming. Smoking helped contribute to patients blockage in femoral artery.

2. Fall 2015: Angiogram was ordered after it was found that the patients blood flow to their toes was not sufficient. Angiogram found a blockage 4inches in super femoral artery.

2.1. This blockage helped lead to the eventual right trans metatarsal amputation

2.2. Patient taking Acetlysalicyclic acid. Used to suppress inflammation, relieve pain, and protect against an MI and ischemic stroke. Also suppresses platelet aggression. Patient is on this medication to help reduce the chance of another clot forming.

3. Smoker for 30 years.

4. Type ll DM

4.1. This has caused neuropathy of the lower extremities, as well as a loss of sensation. This has helped contribute as to one of the reasons why the patient did not realize how badly injured his right toe was on impact that night. Due to this loss of sensation, the patient did not attend the injury as needed. DM increases risk for clots. This may have been a contributing factor to the blockage that was found in patients femoral artery.

4.2. Medications taken for type ll DM: Insulin Detemir: Long acting antidiabetic that helps decrease blood glucose. Metformin: Antidiabetic. Inhibits hepatic glucose production and increases sensitivity of peripheral tissue to insulin. This helps to maintain blood glucose at normal levels. Pioglitazone: Antidiabetic. Specifically targets insulin resistance. Sitagliptin: Antidiabetic: slows the inactivation of incretin hormones, improves glucose homeostasis, improves glucose dependent insulin secretion, lowers glucagon secretions and slows gastric emptying time.

5. GERD

5.1. Patient taking Ezetrol. this antilipemic inhibits absorption of cholesterol by the small intestine. This helps decrease cholesterol levels.

6. Asthma

6.1. Patient taking Budesonide. This glucocorticoid helps prevent inflammation by depression of migration of polymorph nuclear leukocytes, fibroblasts, reversal of increased capillary permeability and lysosomal stabilization. This helps to remove,lessen asthmatic symptoms.

7. May 15, 2015. Patient kicked bedpost during night. Patient did not feel the sensation that damage had occurred. As a result, patient ignored initial injury.Toe nail turned black, and necrosis occurred. The bone protruded through skin. Right toe got Osteomyletis. Surgery Nov. 2015 for half R. toe amputation. Healing did not occur optimally due to poor circulation.

7.1. This connects to patients history of smoking as well as type ll DM.

7.2. Because healing did not occur, patient readmitted to hospital for total right metatarsal amputation.

7.2.1. This amputation was because of a few different factors. These factors are linked to patients history of smoking, DM, and hypertension. All of these factors helped cause the poor perfusion and delayed healing time.

7.3. Patient taking acetaminophen around the clock for pain associated with amputation. This drug helps reduce fever and pain the patient is feeling post amputation.

7.4. Patient is taking Cefazolin to help prevent anohter infection post surgery. This is an antibiotic that is being used to help prevent a bacterial infection post surgery.

7.5. Patient is taking Metronidazole post surgery prophylaxis because of high risk of anaerobic infection.

8. SDOH - Income: Medium income class - Education: College - Employment: - Personal Health practices:

9. Lots of family support. Family and friends were seen visiting daily. Patient reported this was helping his cope and deal with his prognosis.

9.1. Patient was discharged earlier than was originally anticipated. Family support has been found to help patients recover at a faster rate.

10. PRN Medications for post surgery: Hydromorphone: Opioid analgesic, Opioid Agonist. Binds to opioid receptors in CNS. Alters perception of and response to pain stimuli while producting generalized CNS depression. This is ordered to help manage pain as needed. Metoclopramide: Dopamine-recoptor antagonist; antiemetic. D2 receptor antagonist helps prevent nausea and vomiting. This medication is PRN to help counteract any nausea that may be experienced by the other medications patient is currently being administered. Oxycodone: Opiod that works as an agonist on opiod receptors in the brain producing the effects of analgesia. Used for PRN treatment of pain. Tramadol: Analgesic that binds to u receptors and inhibits reuptake of nonepinepherine, serotonin. Patient prescribed this PRN for relief of pain post surgery.

11. Hypertention. A state of sustained abnormally high blood pressure. This sustained increase of BP can cause damage to the heart and coronary arteries, including MI, heart disease, CHF, and atherosclerosis. Patients hypertention may have contributed to blockage in femoral artery, by causing atherosclerosis of the arteries. This in turn caused poor blood perfusion to the foot, eventually causing necrosis of injured metatarsal.