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    Case Presentation: Bernamieh O. Calam-Pastor, MD

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    Bernamai Calam
    This case presents a 70 year old male with diabetes and hypertension who presented with a non-healing wound on his right second toe. His initial impression was diabetic foot. Differential diagnoses considered were diabetic neuropathy, peripheral arterial disease, and chronic venous insufficiency. He underwent toe disarticulation and was managed with antibiotics, wound care, insulin, and monitoring of blood sugars and labs. Diabetic foot complications arise from neuropathy and vascular disease and require multidisciplinary management.

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    Case Presentation: Bernamieh O. Calam-Pastor, MD

    Uploaded by

    Bernamai Calam
    47 views51 pages
    This case presents a 70 year old male with diabetes and hypertension who presented with a non-healing wound on his right second toe. His initial impression was diabetic foot. Differential diagnoses considered were diabetic neuropathy, peripheral arterial disease, and chronic venous insufficiency. He underwent toe disarticulation and was managed with antibiotics, wound care, insulin, and monitoring of blood sugars and labs. Diabetic foot complications arise from neuropathy and vascular disease and require multidisciplinary management.

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    This case presents a 70 year old male with diabetes and hypertension who presented with a non-healing wound on his right second toe. His initial impression was diabetic foot. Differential diagnoses considered were diabetic neuropathy, peripheral arterial disease, and chronic venous insufficiency. He underwent toe disarticulation and was managed with antibiotics, wound care, insulin, and monitoring of blood sugars and labs. Diabetic foot complications arise from neuropathy and vascular disease and require multidisciplinary management.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    47 views51 pages

    Case Presentation: Bernamieh O. Calam-Pastor, MD

    Uploaded by

    Bernamai Calam
    This case presents a 70 year old male with diabetes and hypertension who presented with a non-healing wound on his right second toe. His initial impression was diabetic foot. Differential diagnoses considered were diabetic neuropathy, peripheral arterial disease, and chronic venous insufficiency. He underwent toe disarticulation and was managed with antibiotics, wound care, insulin, and monitoring of blood sugars and labs. Diabetic foot complications arise from neuropathy and vascular disease and require multidisciplinary management.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 51

    CASE

    PRESENTATION

    Bernamieh O. Calam-Pastor,
    MD
    GENERAL DATA
    J. P
    70/ Male
    Married
    Pagatpat, Cagayan de Oro City
    Religion
    Retired Army
    CHIEF COMPLAIN

    Non healing wound 2nd digit, Right


    foot
    BASELINE FUNCTIONAL
    CAPACITY
    • Can do ADLs and ambulate without assistance
    • No exertional dyspnea
    • No orthopnea
    • No bipedal edema
    HISTORY OF PRESENT
    ILLNESS
    - Erythematous swelling at 2nd digit R
    foot
    - Gnawing pain
    - Undocumented fever
    - Paracetamol 500mg 1 tab
    - Condition tolerated

    2weeks
    PTA
    HISTORY OF PRESENT
    ILLNESS
    - Persistence:
    swelling
    gnawing pain
    - Discoloration of affected area
    - No fever

    2weeks
    Interim
    PTA
    HISTORY OF PRESENT
    ILLNESS
    - Increasing involvement of blackish
    discoloration
    - Sought consult w/ AP
    - Labs requested
    - Prescribed w/ meds
    - Advised for ff up w/ labs

    2weeks 5days
    Interim
    PTA PTA
    HISTORY OF PRESENT
    ILLNESS
    - Ff-up check up w/ lab results
    - Revision of medications
    - Referred to Dr. Khu
    - Advised for disarticulation of affected toe

    2weeks 5days 2days


    Interim
    PTA PTA PTA
    11/19/20

    CBC: Hgb 10.3/ Hct 29.7/ wbc 9.82/ Plt 396 Urinalysis:
    N 74.1/ L 17.4/ M 6/ E 2.5 light yellow/ sl hazy/ pH 6/sg 1.010/ albumin +2/
    CHO -/ rbc 0-2/ wbc 15-20/ epith rare
    FBS: 137.5
    BUN: 27.33
    Crea: 3.10 (eGFR 19/ Ccr22)
    BUA: 8

    Lipid profile: Cho 221.3/ Trig 289.5/ HDL 22.4/ LDL 141.1/ VLDL 57.9/
    %HDL 10.12/ LDL-HDL ratio 6.3

    SGPT: 26.4
    Na: 139 CXR PA:
    K: 4.1 Tortous and atherosclerotic aorta
    Cl: 113
    HbA1c: 7.88
    HISTORY OF PRESENT
    ILLNESS

    2weeks 5days 2days


    Interim ADMITTE
    PTA PTA PTA
    D
    PAST MEDICAL HISTORY
    (+) Hypertension – 20 yrs
    (+) Diabetes – 20 yrs
    (+) Past Hospitalization: MVA 1978, V. Luna Hosp
    (-)Previous TB Treatment

    Maintenance:
    Amlodipine 10mg 1 tab OD
    Losartan 50mg 1 tab OD
    Metformin 500mg 1 tab OD
    FAMILY HISTORY
    ‍
    ‍
    Diabetes
    Hypertension

    Cancer
    Asthma
    SOCIAL HISTORY Smoker
    8 pack years

    ETOH-
    occasional
    👤
    No Known
    FDA
    REVIEW OF SYSTEMS (-)chest pain, (-)palpitations,
    (-)orthopnea
    (-)fever, (-)weight loss, (-) loss of appetite,
    (-) night sweats
    (-)diarrhea, (-)constipation, (-)melena,
    (-)hematochezia, (-)abdominal pain
    (-)skin rash, (-) pruritus
    (-)polydipsia, (-)polyphagia, (-)heat/cold
    (-)dizziness, (-)blurring of vision, intolerance, (-)polyuria,
    (-)diplopia, (-)dysuria, (-)urinary incontinence, (-)urgency
    (-)hearing loss, (-)ear discharges,
    (-)tinnitus, (-)epistaxis, (-) hoarseness, (-)joint pains, (-)myalgia, (-)limitation of
    (-)dysphagia, (-)nasal discharge movement

    (-)cough, (-)dyspnea, (-)hemoptysis,


    (-)tremors, (-)sensorium change, (-)memory
    (-)pleurisy
    loss, (-)decrease in coordination,
    (-)headache, (-)body weakness, (-)loss of
    consciousness
    VITAL SIGNS 36.2 ℃

    70 kg 20 cpm

    158 cm 97 bpm

    130/80
    28 kg/m² mmHg

    98%
    PHYSICAL EXAMINATION
    General: awake, alert, conscious, coherent, NIRD
    HEENT: anicteric sclerae, pink palpebral
    conjunctivae
    C/L: equal chest expansion, clear breath sounds
    CVS: distinct heart sound, no murmur
    Abd: flat, NABS, soft, non tender
    GUT: (-) KPS
    Ext: strong peripheral pulses, CRT <2, irregular
    border of black discoloration at the distal phalanx;
    R foot
    MENTAL STATUS: Oriented, intact memory, good judgement and reasoning

    NEURO EXAM
    CRANIAL NERVES:
    I- smell without difficulty
    II- pupils equally reactive to light and accommodation
    III, IV, VI- intact EOM movements, no nystagmus
    V- intact facial sensation
    VII- (-) facial asymmetry; intact facial muscle strength
    VIII- no sensorineural hearing loss
    IX, X- (+) gag reflex
    XI- (+) shrug shoulders
    XII- (-) tongue deviation

    MOTOR: 5 5
    5. 5

    SENSORY: 100%
    REFLEX: +2 all extremities
    COORDINATION: good finger to nose test, no dysdiadokokinesia
    SALIENT FEATURES
    HISTORY PE

    • 70 year old • non healing wound


    • Male • black discoloration
    • Diabetic of 2nd digit R foot
    • Hypertensive • Strong peripheral
    • Family hx of DM surface
    and HPN • Sensory 100%
    IN A NUTSHELL..
    A case of a 70 year old male, known hypertensive and diabetic
    who presented with a non healing wound
    INITIAL IMPRESSION

    Diabetic foot, Right 2 digit


    nd
    DIFFERENTIAL DIAGNOSIS Diabetic
    Neuropathy
    “DM Foot”

    Non-
    healing
    wound/
    Chronic ulcer Peripheral
    Venous arterial
    Insufficienc occlusive
    y disease
    NEUROPATHIC ULCER Diabetic Neuropathy “DM Foot”

    RULED IN RULED OUT

    Diabetes Painless?

    Pressure sites

    Thick callus surrounding affected area


    ARTERIAL (ISCHEMIC) ULCER Peripheral arterial occlusive disease

    RULED IN RULED OUT


    Cigarette smoking Weak/absent peripheral pulses
    Diabetes Prolonged capillary refilling time (>3 to 4
    Dyslipidemia seconds)
    Intermittent claudication Pallor on leg elevation (45° for 1 min
    Pressure sites Severe pain
    Distal points (toes)
    VENOUS ULCER Chronic Venous Insufficiency

    RULED IN RULED OUT

    most common cause of leg ulcers female sex, obesity, pregnancy, prolonged
    standing, and a history of deep venous
    thrombosis
    advancing age Gaiter distribution
    Malleolar regions

    Mild to moderate pain

    Irregular borders; Shallow


    WHAT WAS DONE..
    IVF: PNSS 1L at 20gtts/min
    Diet: low salt, low fat, diabetic
    Therapeutics:
    Amlodipine 10mg 1 tab OD
    Losartan 50mg 1 tab OD
    Clindamycin 300mg 1 tab QID
    Ceftriaxone 2gm IV OD
    Omeprazole 40mg IV shifted to 1 cap OD ACBF
    Atorvastatin 40mg 1 tab ODHs
    Ketoanalogue 600mg tab 2 tabs TID
    Regular Insulin PRN
    Plan:
    For Toe Disarticulation under digital block
    RESULTS
    HGT: 97 mg/dL

    CBC:
    Hgb 9.8/ Hct 29/ Wbc 9 920/Plt 396 000
    S 76/ L 17/ M 5/ E 2

    K: 4.3
    Crea: 3.22 (eGFR 18/ Ccr 21)
    RESULTS
    RESULTS
    RESULTS
    DIABETES MILLETUS Case Discussion
    DIABETES MILLETUS
    - phenotype of hyperglycemia
    -factors:
     reduced insulin secretion
     decreased glucose utilization
     increased glucose production
    CLASSIFICATION
    TYPE 1 DM
    - autoimmunity against the insulin-producing beta cells

    TYPE 2 DM
    - insulin resistance, impaired insulin secretion, and increased
    hepatic glucose production
    DIAGNOSIS
    RISK FACTORS
    MANAGEMENT
    COMPLICATIONS
    LOWER EXTREMITY COMPLICATIONS
    DIABETIC FOOT
    Risk factors:
     Neuropathy
     Peripheral vascular disease
     Poor glycemic control
    ETIOLOGY

    Depending on the extent:

    •Superficial
    -aerobic gram-positive cocci
    •Ulcers
    -polymicrobial
    •Extensive wounds
    -anaerobic organisms
    DIAGNOSIS
    Evaluation:
    1. determining the extent and severity of infection
    2. identifying underlying factors that predispose to and promote infection
    3. assessing the microbial etiology
    MANAGEMENT
     Wound management
    Good nutrition
    Appropriate antimicrobial therapy
    Glycemic control
    Fluid and electrolyte imbalance
    WOUND MANAGEMENT

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