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Diabetic Foot Ulcer

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by

Leon Foo

on 22 November 2013

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Transcript of Diabetic Foot Ulcer

Case Presentation
Summary
33 years old with premorbid illnesses of long standing DM, HTN, Hyperlipademia, with multiple admissions to hospital presented with recurrent ulcers over the plantar aspect of Lt midfoot and lateral border dorsum of Lt foot with seropurulent, foul smelling discharge within 1 year, Lt foot swelling for 1 week and pain a day prior to hospital admission with itchiness and intermittent fever and also difficulty on walking.

General Examination
Vitals:
BP: 130/88mmHg
Pulse: 80 /m, regular, normal volume, with vessel thickening.
Respiratory rate: 18/min
Temperature: Clinically afebrile

Head to Toe Examination:
No pallor, icterus, cyanosis
Pitting pedal edema with hyperpigmentation of skin over Lt leg(up to the level below knee)
Presence of multiple excoriation marks throughout skin distribution(due to diabetic dermatopathy)

Palpation-
Rt leg -
Normal

Left leg -
Increase local temperature over the swollen area
No tenderness
Ulcer-
Plantar aspect of foot – base: non mobile, does not bleed on touch
Lateral border dorsum of foot – base: non mobile, minimal blood discharge
Regional lymph node-not palpable nodes in inguinal region

Leon Foo Jing En Batch 24 Group F2
Patient Profile
Name: Mr. R
Age: 33 years old
Race: Indian
Gender: Male
Address: Tampin, Negeri Sembilan
Occupation: Unemployed

Chief Complaint
Lt foot ulcers for 1 year
Lt foot swelling for 1 week
Lt foot pain for 1 day

HOPI
Patient is known case of long standing DM for 12 years ago (since age 21 years)
The ulcer started since 1 yr ago due to ill-fitting shoe. Size of ulcer is
around 1 inch
at plantar aspect of Lt midfoot,
minimal pain
with
no discharge, non-foul smelling
, does not healed after 1 week which made him to see the doctor
2 months back,
another ulcer
develop at lateral border dorsum of foot due to trauma; slit-like with size of 1 inch, painful, associated with foul smelling seropurulent discharge and itchiness over the surrounding skin

He was still able to do routine daily activities with minimal
restriction
due to pain and discomfort
He underwent several procedures of debridement and regular dressing for the underlying ulcers which were poorly healed at the hospital
1 week prior to admission
, he noticed sudden
Lt foot swelling
up to the level of ankle joint, associated with
itchiness
, aggravated by movement and not subsides by any measures. He avoid excessive movement at ankle due to discomfort

A day prior to admission, he had sudden, continuous, throbbing
Lt foot pain
at ulcerated part (lateral border), moderate in severity and associated with minimal seropurulent, foul smelling discharge oozing out from the ulcer, aggravated by movement and relieved by analgesic. There is also
history of low grade, intermittent fever for 3 days
and subsides by medication without chills and rigor
Patient has to use
walking aid
for walking
No history of discharging bone pieces from the wound.
No history of stroke.
SYSTEMIC REVIEW: not significant

Local examination
Inspection-
Antalgic gait, Attitude - neutral position
Normal hair distribution and sweating bilaterally, brittle toe nails
Rt leg -
Normal

(Over affected part-
Lt leg
)
hyperpigmentation over Lt leg up to level below knee
pitting pedal edema upto level below knee
Ulcer
-
Plantar aspect of foot
-oval in shape,10×7×1 cm in dimension, involving midfoot , regular margin, slopping edge, floor- pale granulation tissue, with skin induration over surrounding ulcerated area
Lateral border dorsum of foot
-elongated,7×3×3 cm in dimension over midfoot, irregular margin, slopping edge with yellowish foul smelling discharge and slough and necrotic debris, dry scaly skin over surrounding area

Movement
Measurement
- no limb length discrepancy
Neurological status
Vascular status:
Posterior tibial artery and dorsalis pedis artery felt at both sides
Capillary refilling time is normal(<2sec)
Neurovascular examination
Clinical Diagnosis
Infected diabetic foot ulcers on the plantar aspect and lateral border dorsum of midfoot at Lt foot with peripheral neuropathy

Investigations
Pus- culture & sensitivity
FBC, ESR- infection
X ray of foot- involvement of bone
Daily blood sugar monitoring, HbA1c, ophthalmoscope, RFT
MRI- rule out OM
Pre-anaesthetic investigations if plan for operation: ECG, CXR, LFT

Treatment
Conservative
Advice: Check foot everyday, wash foot everyday, trim nails regularly, wear shoes and socks all the time, avoid pressure on affected foot, check shoes for any rough spots that cause sores, avoid feet from hot and cold.
Control diabetes: compliant to medication and diabetic diet
Underlying infection: administer antibiotic

Surgical
Wound debridement for spreading ulcer
Incision and drainage for abscess
Curettage for OM
Disarticulation/ amputation for gangrene
Full transcript