Blame it on the “tack”. . .
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Transcript of 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
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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
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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
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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 Examination
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
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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
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Physical ExaminationPhysical Examination
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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
Physical ExaminationPhysical Examination
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
Laboratory WorkupsLaboratory Workups
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
Laboratory WorkupsLaboratory Workups
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.
Laboratory WorkupsLaboratory Workups
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
Laboratory WorkupsLaboratory Workups
• (+) 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
Test Male reference range 11/09/09
Creatinine 0.5-1.2 mg/dL 0.48
HBA1c 4.8 – 6 % 11.11
Sodium 137-147 mmol/L 134
Potassium 3.8-5 mmol/L 4.3
SGPT - ALT 0-41 U/L 26.2
Fasting Blood Sugar 70.9 – 110 mg/dL 296
Laboratory WorkupsLaboratory Workups
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
Test Male reference range 11/09/09
Creatinine 0.5-1.2 mg/dL 0.48
HBA1c 4.8 – 6 % 11.11
Sodium 137-147 mmol/L 134
Potassium 3.8-5 mmol/L 4.3
SGPT - ALT 0-41 U/L 26.2
Fasting Blood Sugar 70.9 – 110 mg/dL 296
Laboratory WorkupsLaboratory Workups
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
Laboratory WorkupsLaboratory Workups
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
http://www.icmr.nic.in/guidelines_diabetes/section6.pdf
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
http://www.icmr.nic.in/guidelines_diabetes/section6.pdf
Non-pharmacologic
• Stress management– Behavioral modification
to develop positive attitude and healthy lifestyle
– Quality of life– Coping skills– Optimal family support– Counselling
http://www.icmr.nic.in/guidelines_diabetes/section6.pdf
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: