blame it on the “tack”.

Blame it on the “tack”. . .

B3B: Dr. Marilyn Ong - MateoFajardo, Revie; Fang, Mark; Florendo, Gerard; Fontano, Michael;

Francisco, Therese; Gabuat, Harry; Gaffud, Bianca; Gagtan, Majelle; Gallardo, Heart; Garan, Aileen; Garcia, Cholson; Garcia, Louise;

Garcia, Irka

HISTORY

General DataGeneral Data

• A.B• 49/M• Filipino• Roman Catholic• Paranaque City• Married• Fruit Vendor• Date of Admission: Nov 9, 2009

Chief ComplaintChief Complaint

* Painful swelling of the left foot (heel) *

AB: 49/M known diabeticHistory of Present IllnessAB: 49/M known diabeticHistory of Present Illness

AB: 49/M known diabetic x 12 yearsHistory of Present Illness

AB: 49/M known diabetic x 12 yearsHistory of Present Illness

Past Medical HistoryPast Medical History

• Immunizations: unrecalled; BCG• Hospitalizations:

– non-healing wound : unrecalled antibiotics (1997)– Hemoptysis- CXR: PTB; Rx: Myrin Forte (HRZE) 6

months (approx. 5 yrs ago) • Diabetes Mellitus (1997)• Medications: Glibenclamide 500mg OD• No surgery• No allergies

Personal and Social HistoryPersonal and Social History

• 16 pack year smoking• Alcohol drinker 2 bottles of beer/night• Mixed diet ; cautious with sweets• Exercise: sidecar (padyak) in selling fruits• Sleep:4-6 h/day

Family HistoryFamily History

• (+)DM: sister- deceased due to ‘heart attack’ (52 years old)

• Father - deceased- sudden death(age?)• (+)cataract: mother• (-) asthma, HPN, CA

Review of SystemReview of SystemGENERAL SURVEY:( - ) fever( - ) weight loss( - ) weakness( - ) fatigability( - ) malaise

SKIN:( +) 3 inch-scar on the lateral aspect of

the left leg ( - ) itchiness( - ) color change( - ) rash

HEENT:( - ) icterus( - ) ear pain/ discharge( - ) nasal discharge( - ) deafness( - ) lymphadenopathy

PULMONARY:( - ) dyspnea( - ) shortness of breath( - ) cough( - ) sputum production( - ) hemoptysis( - ) wheezing

CARDIAC:( - ) chest pain( - ) easy fatigability( - ) paroxysmal dyspnea( - ) orthopnea( - ) palpitations( - ) syncope( - ) edema( - ) hypertension

GI:( - ) nausea( - ) vomiting( - ) retching( - ) hematemesis( - ) melena( - ) hematochezia( - ) belching( - ) distention( - ) diarrhea( - ) constipationGU:

( + ) polyuria( + ) incontinence( + ) erectile dysfunction ( - ) anuria( - ) dysuria( - ) hesitancy

MUSCULOSKELETAL:( - ) rigidity( - ) flaccidity( - ) weakness

Review of SystemReview of System

ENDOCRINE:( + ) polydipsia( + ) polyphagia ( - ) heat/cold intolerance

HEMATOPOIETIC:( - ) bleeding tendency( - ) bruisability

NEUROLOGIC:( - ) numbness( - ) tingling( - ) burning( - ) sharpness( - ) motor weakness

Review of SystemReview of System

Physical ExaminationPhysical Examination

On Admission (11/9/09) 12/11/09

Conscious, coherent, wheelchair-borne, not in cardiorespiratory distress

Conscious, coherent, not in cardio respiratory distress, afebrile, wheelchair- borne

BP: 100/70mmHg PR: 80bpm, regular RR: 20 breaths/min, regular T: 36.5° C

BP: 120/90mmHg PR: 80bpm, regular RR: 18 breaths/min, regular T: 37.5° C

Ht: 165cm Wt: 71kgBMI: 26.08 kg/m2

Ht: 165cm Wt: 65 kgBMI: 23.8 kg/m2, slightly overweight

13

Physical ExaminationPhysical ExaminationOn admission (11/9/09) 12/11/09

Skin Warm, moist skin, no active dermatoses

no discoloration nor hyperpigmentation, no alopecia, warm

HEENT Pink palpebral conjunctivae, anicteric sclera, pupils 2-3 mm ERTL

No nasoaural discharge, nonhyperemic

PPW, tonsils not enlarged

Supple neck, thyroid not enlarged, no palpable cervical lymph nodes, no masses

Pink palpebral conjunctivae, anicteric sclera

No nasoaural discharge, non-hyperemic

Supple neck, thyroid not enlarged, no palpable cervical lymph nodes, no masses

14

Physical ExaminationPhysical ExaminationOn Admission (11/9/09) 12/11/09

Respiratory Symmetrical chest expansion, no retractions, clear breath sounds

Symmetrical chest expansion, no retractions, good transmission of spoken words, resonant, clear breath sounds

Cardiovascular Adynamic precordium, AB 5th LICS MCL, normal S1, S2(-) murmurs

JVP: 5 cm at 30O angleCAP: rapid upstroke gradual downstrokeAdynamic precordium, AB 5th LICS MCL, apex: S1>S2 base: S2>S1(-)murmurs

15

On Admission (11/9/09)

12/11/09

Pulses No cyanosis, pulses full and equal

Brachial artery (++) (++)

Femoral artery (++) (++)

Popliteal artery (++) (++)

Posterior tibial artery

(++) (++)

Dorsalis pedis artery

(+) (+)


Physical ExaminationPhysical ExaminationOn Admission (11/9/09) 12/11/09

Gastrointestinal Flat soft abdomen, normoactive bowel sounds, no masses

Flat soft abdomen, normoactive bowel sounds,no tenderness, no masses, liver span: 10cm

Musculoskeletal (+) 3X3cm tender ulceration at medial calcaneal area of left foot erythema, edema and yellowish discharge

(+) 3X3cm erythematous, swollen, tender lesion with ulceration and yellowish discharge at the medial calcaneal area of left foot

17

Neurologic Exam

On Admission (11/9/09) 12/11/09

GCS 15(E4,V5,M6)

Motor Normal muscle bulk and tone; no atrophy of thenar and hypothenar eminences, MMTs 5/5 on both UE and LE

Sensory (-) sensory deficits, (-) Babinski,

Reflexes DTRs ++ on all extremities

Coordination Unable to walk due to swelling and pain, limited movements

19


20

On Admission (11/9/09) 12/11/09

Cranial Nerves(-) anosmia; (+) ROR, clear disc margins; pupils 2-3 mm ERTL, (-) L peripheral vision; EOMs full and equal; V1V2V3 intact; raises eyebrows equally, clenches jaw, smiles and puffs cheeks; (-) facial asymmetry, (+) corneal reflex; (+) bilateral gag reflex; uvula midline on phonation; shrugs shoulders equally against resistance; tongue midline on protrusion


SUBJECTIVE OBJECTIVE•( + ) history of DM manifested as 3 P’s and hx of non-healing wound in the past•Heavy alcoholic drinker (2 bottles of beer/night

Afebrile, 37.5° C BP: 120/90mmHg PR: 80bpm, regular wheelchair- borne BMI=23.8radial pulse ++; dorsalis pedis +

Salient FeaturesSalient Features

49 y/o malePainful, swollen, erythematous, ulcerated lesion with purulent discharge, left calcaneal area

SUBJECTIVE OBJECTIVE (+)DM: sister- deceased due to ‘heart attack’ (+)cataract: mother ( +) 4 inch-scar on the lateral aspect of the left leg Unremarkable hematologic,cardiovasular and neurologic symptoms

Unremarkable hematologic and other cardiovascular findingsNo foot deformityUlcerations on the left medial and lateral malleoli

Salient FeaturesSalient Features

Clinical Impression

• Non-healing Wound, Left calcaneal area• Diabetes mellitus, Type 2, Insulin-requiring

Initial Orders

• CBC• Wound secretion gm stain, C/S• FBS, glycosylated hemoglobin• CBG monitoring with sliding scale-directed

insulin administration• Chest X-Ray

Complete Blood Count Reference range 11-03-09Hgb 120-170g/L 148RBC 4.0-6.0 x 1012/L 4.90Hct 0.37-0.54 0.44MCV 87 + - 5 U3 90.40MCH 29 + - 2 Pg 30.20MCHC 34 + - 2 g/dL 33.40RDW 11.6-14.6 11.90MPV 7.4-10.4 fL 6.40Platelet 150-450 x 109/L 450WBC 4.5-10.0 x 109/L 26.20 Neutrophil 0.50-0.70 0.90 Metamyelocyte - Bands 0.00-0.05 0.02 Segmenters 0.50-0.70 0.88 Lymphocyte 0.20-0.40 0.09 Monocyte 0.00-0.07 - Eosinophil 0.00-0.05 x 103 0.01 Basophils 0.00-0.01 - Blast - - Promyelocytes - - Myelocytes - -

Laboratory WorkupsLaboratory Workups

Microbiology Examination (11/10/09)

•Specimen: Wound discharge•Examination: Gram’s stain•Results: Gram (+) cocci singly and in pairs FEW•Pus cells +++•Epithelial cells FEW


Test Male reference range 11/09/09

Fasting Blood Sugar 70.9 – 110 mg/dL 296

HBA1c 4.8 – 6 % 11.11

Creatinine 0.5-1.2 mg/dL 0.48

Sodium 137-147 mmol/L 134

Potassium 3.8-5 mmol/L 4.3

SGPT - ALT 0-41 U/L 26.2


Chest X-Ray (11/09/09)

•Suspicious ill-defined densities are seen in the left infraclavicular area. Suggest apico-lordotic view.

•The rest of the lung fields is clear.•The heart is not enlarged.•Diaphragm and sinuses are intact.


Question to the group

• Do you think there’s a need to establish vascular (arterial) integrity of the lower extremity in this patient?

• If yes, what test would you recommend? Arterial Duplex Scan?

Management

• Antibiotics given??• Proper foot care especially among diabetics • Hydration??• Diabetes management?? CBG Monitoring and insulin therapy?? Dietary instruction??

Final Diagnosis

• ????• Take home instructions and medications

Succeeding slides should focus on the following:

• Why diabetics are prone to develop non-healing wounds• What microorganisms are usually involved • Journals- any new updates on wound care and treatment of

non-healing wounds among diabetics. Please search local journals also.

AFTER ABOVE- FINISH!!!The rest of your beautiful slides- HIDE! HIDE! HIDE!

UrinalysisPhysical Characteristics Microscopic Findings

Color Yellow Red Blood Cell 0-1/hpfTransparency Slightly turbid Pus cell 0-3/hpfpH 5.0 Yeast cellSpecific gravity 1.020 Squamous cellChemical test Renal cellAlbumin NEGATIVE Transitional epithelial Sugar ++++ Bacteria Few Microscopic findingsCast

Mucus threads

Hyaline CrystalsGranular Amorphous uratesWaxy Uric acidPus cell Calcium oxalateRed Blood Cell Amorphous phosphate

Triple phosphate


• (+) polyuria; polydipsia; polyphagia• Erectile dysfunction• Non-healing wound/ulcer• Grossly inflammed left foot• Decreased pulses of the dorsalis pedis artery

49 y/o Male, DM249 y/o Male, DM2

Initial Clinical Impression: history & PE

• Non healing wound to consider soft tissue infection secondary to DM2



HBA1c 4.8 – 6 % 11.11



SGPT - ALT 0-41 U/L 26.2



Complete Blood Count Reference range 11-03-09Hgb 120-170g/L 148RBC 4.0-6.0 x 1012/L 4.90Hct 0.37-0.54 0.44MCV 87 + - 5 U3 90.40MCH 29 + - 2 Pg 30.20MCHC 34 + - 2 g/dL 33.40RDW 11.6-14.6 11.90MPV 7.4-10.4 fL 6.40Platelet 150-450 x 109/L 450WBC 4.5-10.0 x 109/L 26.20 Neutrophil 0.50-0.70 0.90 Metamyelocyte - Bands 0.00-0.05 0.02 Segmenters 0.50-0.70 0.88 Lymphocyte 0.20-0.40 0.09 Monocyte 0.00-0.07 - Eosinophil 0.00-0.05 x 103 0.01 Basophils 0.00-0.01 - Blast - - Promyelocytes - - Myelocytes - -




HBA1c 4.8 – 6 % 11.11



SGPT - ALT 0-41 U/L 26.2



UrinalysisPhysical Characteristics Microscopic Findings

Color Yellow Red Blood Cell 0-1/hpfTransparency Slightly turbid Pus cell 0-3/hpfpH 5.0 Yeast cellSpecific gravity 1.020 Squamous cellChemical test Renal cellAlbumin NEGATIVE Transitional epithelial Sugar ++++ Bacteria Few Microscopic findingsCast

Mucus threads

Hyaline CrystalsGranular Amorphous uratesWaxy Uric acidPus cell Calcium oxalateRed Blood Cell Amorphous phosphate

Triple phosphate


Secondary Clinical Impression:hisotry, PE, laboratory workups

• Non healing wound to consider soft tissue infection secondary to DM2

non-healing foot ulcer

Final Clinical Impression:

• Non healing wound with soft tissue infection secondary to DM2

PATHOPHYSIOLOGY

Management

Non Pharmacologic

Goals of therapy

• Eliminate symptoms related to hyperglycemia• Reduce or eliminate long-term microvascular

and macrovascular complications• Allow patient to achieve a normal lifestyle as

possible

Harrison’s Principle of Internal Medicine 17th edition, 2008

Non-pharmacologic

• Diet– Achieve and maintain

ideal body weight, euglycemia and desirable lipid profile

– Prevent and postpone complications

– Provide optimal nutrition

http://www.icmr.nic.in/guidelines_diabetes/section6.pdf

Non-pharmacologic

• REGULAR physical activity– Individualized– Wear appropriate

footwear– Recommendation:

stepwise increase of aerobic exercise

– Exercise for at least 30mins during most days of the week


Non-pharmacologic

• REGULAR physical activity– Benefits:

• Improvement in insulin sensitivity• Reduction of hypertension• Reduction in weight• Improvement in lipid profile (dec. serumTG, inc. HDL)• Improvement in cardiovascular function• Increase bone density• Improvement of quality of life


Non-pharmacologic

• Stress management– Behavioral modification

to develop positive attitude and healthy lifestyle

– Quality of life– Coping skills– Optimal family support– Counselling


www.zazzle.co.uk/reishi+gifts

Goal: obtain wound closure

• Rest, elevation, relief of pressure

• Debridement of all necrotic, callus and fibrous tissues

Management

Pharmacologic

Objectives

• Provide antidiabetic medication for poorly controlled Type 2 DM

• Create an antibiotic regimen that will cover the isolated organism from the culture

Anti-diabetic Agents

• Primary correction needed in patients with diabetic foot is to correct the underlying metabolic disorder

• Correction of DM can be accurately done via administration of anti-diabetic agents

• IV Insulin preparation deems necessary for our patient

Insulin Preparations

• Ultra-rapid and very short acting– Insulin lispro

• Rapid and short acting– Crystalline zinc (regular) insulin

• Intermediate onset – NPH and lente

• Slow onset and long acting– ultralente

Antibiotic therapy

• Culture obtained from the patient’s discharge in the foot demonstrated Gm (+) cocci singly and in pairs

• Antibiotic treatment for such organisms can be effectively cured by antibiotics with Gm + coverage

• Staphylococcus organisms are typically treated with penicillinase-resistant Beta lactams

Penicillinase-resistant Beta lactams

• Methicillin• Oxacillin• Nafcillin• Dicloxacillin• sultamicillin

PREVENTION

Preventing Foot Problems

• Take daily care of feet– Wash feet– Trim toenails– Inspect feet for injuries

• Wear proper foot wear• Prevent injury to feet• Visit healthcare

provider regularly

http://www.nlm.nih.gov/medlineplus/tutorials/diabetesfootcare/db029103.pdfwww.wellsphere.com/.../tests-for-diabetic-foot

www.drchristi.com/footcarediabetesfungalfootcare

• Keep the Blood Flowing to the Feet

– DO NOT cross your legs for long periods of time. – DO NOT wear tight socks, elastic, or rubber bands, or

garters around your legs. – DO NOT wear restrictive footwear or foot products. Foot

products that can cut off circulation to the feet, such as products with elastic, should not be worn by diabetics.

– DO NOT smoke. Smoking reduces blood flow to your feet. If you have high blood pressure or high cholesterol, work with your health care team to lower it.

• Be More Active

http://www.nlm.nih.gov/medlineplus/tutorials/diabetesfootcare/db029103.pdf

• Harrison’s Principles of Internal Medicine 17th edition• A Review of the Pathophysiology, Classification, and

Treatment of Foot Ulcers in Diabetic Patients. Warren Clayton, Jr., MD, and Tom A. Elasy, MD, MPH

• Diabetic foot infections. Pathophysiology and treatment. Surg Clin North Am. 1994; 74(3):537-55 (ISSN: 0039-6109)Bridges RM; Deitch EADepartment of Surgery, Louisiana State University Medical Center, Shreveport.

• www.health.am

References:

blame it on the “tack”.

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