Physician Discharge Summary     Patient ID:  Age: 74 y.o.  Admit Date: 8/30/2022  1:01 PM  Discharge Date: 9/3/2022   Admitting Physician:   Discharge Physician: MD     Discharge Diagnosis:  Principal Problem:    Gangrene of both feet  Active Problems:    Mild intermittent asthma without complication    Stage 3b chronic kidney disease    Thromboangiitis obliterans (Buerger's disease)    Renal cell carcinoma of left kidney    Sepsis    COVID-19    Essential hypertension    Type 2 diabetes mellitus without complication, without long-term current use of insulin           HPI: Patient is a 74 y.o. female who presents to ED from Vascular office due to worsening R foot infection. Has h/o Buerger's disease and has been seen here at at medical facility. Mostly dry gangrene and R 5th toe auto amputated recently. Has foul smelling drainage to R foot. Dry gangrene to L foot and scatt fingers that do not appear acutely infection. She is at a nursing home and states she had COVID 2 weeks ago, is positive today, denies any respiratory symptoms. Also has h/o renal cell carcinoma, states she has not had treatment due to uncontrolled Buerger's. Was sent here for admission for R foot amputation and IV antibiotics.     Hospital Course:      Patient was seen by vascular surgeon, who recommended R toe 1-4 amputations, L toe 1-3 amputations. Patient underwent toe amputations with  bone shears and  a rongeur was used to remove the residual phalanx and the metatarsal head was resected back to healthy appearing bone.  Plastic surgery was consulted for the Bilateral hand digital dry gangrenous changes without acute ascending cellulitis or tenosynovitis involving left index; right index, middle, and ring fingers to the distal proximal phalanges. Plastic surgery recommended that her gangrenous fingers which appear to be stable dry gangrene progressing to autoamputation over the right ring finger. No acute surgical intervention at this time and continue Betadine paint twice per day.      Infectious disease was consulted, patient was on broad spectrum abx vancomycin, cefepime and metronidazole. After the surgery, the infected bone was removed, patient transitioned to oral meds augmentin and doxycyxline at discharge. Patient discharged back to her nursing home.     * Gangrene of both feet  1. Gangrene of bilateral toes in a patient with h/o Buerger's disease. Imaging finding of osteomyelitis in the right foot toes  2. Right 3rd, 4th, and 5th toe osteomyelitis s/p amputation of the  Right 1st, 2nd, 3rd and 4th toes and Left  1st, 2nd and 3rd toes.  3. Sepsis likely 2/2 toe osteomyelitis, POA, resolved  4. Dry gangrene of the fingers likely 2/2 Buerger's disease     Vascular surgery completed amputations, Infected bone removed. F/up at discharge  Plastic surgery recommend continue painting digits with betadine. F/up at discharge  Oral Augmentin and Doxycycline for 7 days per ID recommendations  Blood culture, no growth at 48 hours.  Continue home pain medications morphine and percocet q4h prn for pain control.        COVID-19  Reports testing positive for COVID 2 weeks ago at nursing home.  Patient asymptomatic, no indications for Remdesivir/Dexamethasone.     Stage 3b chronic kidney disease  Creatinine at baseline. Monitor input and output. Encourage po intake.        Renal cell carcinoma of left kidney  CT guided biopsy of the left iliac crest on 6/22/2022.   Pathology showed: Metastatic adenocarcinoma, suspicious for renal cell origin.  Patient following oncologist at medical facility.  Patient to follow up after discharge.     Thromboangiitis obliterans (Buerger's disease)  Continue Asprin 325 mg daily, Plavix, Imdur 60 mg twice daily.  Continue smoking cessation.        Mild intermittent asthma without complication  Resume home inhaler symbicort at discharge     Type 2 diabetes mellitus without complication, without long-term current use of insulin  Resume home anti diabetes medications     Essential hypertension  Resume home antihypertensives at discharge.                    Physical Exam on the Date of Discharge:  Physical Exam  Vitals reviewed.  Constitutional:       General: She is not in acute distress.    Appearance: She is not ill-appearing.  HENT:      Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:      Extraocular Movements: Extraocular movements intact.  Cardiovascular:      Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: No murmur heard. Pulmonary:      Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: No wheezing.  Abdominal:     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.   Musculoskeletal:     Cervical back: Normal range of motion.     Right Lower Extremity: (toe amputations and dressing in place)    Left Lower Extremity: (toe amputations and dressing in place)  Neurological:      General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood normal.                        Consults:    IP CONSULT TO PLASTIC SURGERY  IP CONSULT TO VASCULAR SURGERY  IP CONSULT TO SOCIAL WORK  IP CONSULT TO INFECTIOUS DISEASES     Significant Diagnostic Studies:     Xray foot        Disposition:  SNF     Discharge Condition:  good