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Robert Frykberg,
DPM, MPH
PRESENT Editor,
Diabetic Limb Salvage |
Cases From The High Risk Clinic
With the New Year I thought it would be beneficial to put our clinical skills to work. Since it is always a challenge to come up with interesting articles that might benefit our readers, a new approach for the New Year might be in order. Therefore, we will explore various cases from our clinics that have posed a problem or at least interesting clinical conundrums for us in our limb salvage efforts. Our format will initially present the clinical scenario (complaints, examination findings, labs, etc.) surrounding a patient’s problem, complete with clinical images. The challenge of then formulating an appropriate treatment plan will be sought with specific "points to ponder". Our clinical management protocols (right or wrong) will then follow in the subsequent issue. So let us begin with our first case, indeed a challenging one – but very typical of complex diabetic foot patients.
CASE ONE:
This 61 year old type 2 diabetic man of 12 years duration had been under our care for several months while treating a neuropathic ulcer under his right first metatarsal head. Despite appropriate offloading and wound care, his ulcer failed to heal – likely due, in part, to his own non-compliance with the prescribed offloading boot. Nonetheless, he presented to our Emergency Department (ED) on a Friday afternoon (don’t they always?) one hot July. The patient was concerned with an odor associated with increasing redness and swelling in the foot. Usually painless, his foot was starting to hurt when he walked on it as well. Having chills and fevers the prior week, the patient thought he had come down with the flu. His glucose levels had been elevated to greater than 250 g/dL when he had last checked several days before. His oral temperature on presentation was 100.2 degrees F. Figures 1 and 2 show the foot upon initial presentation to the ED.
Figure 1 |
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Figure 2 |
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On examination, he was found to have a malodorous full thickness wound under the 1st MTP joint with tendon, bone and joint exposed. Purulent drainage was expressed from the wound on motion of the great toe. There was crepitus on palpation of the foot and ankle with cellulitis noted dorsally and extending to the lower leg. A hemorrhagic blister was noted on the anterior lower leg as well. Loss of protective sensation (LOPS) was evident as had been previously documented, but there was some pain noted on palpation of the foot and leg. Pedal pulses were palpable and Doppler signals were biphasic at bedside examination. Xrays were taken as shown in Figures 3 and 4. Hematology and serology labs were drawn in the ED as well and pertinent results reported as follows:
WBC 36000/ul
Hemoglobin 8.8 g/dL.
Bun 68 mg/dL,
Creatinine 2.9 mg/dL,
eGFR 22 mL/min.
blood glucose 312 g/dL
HgbA1c 9.5%
Gram stain: gram positive cocci, gram negative cocci, gram negative bacilli
Figure 3 |
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Figure 4 |
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This was obviously a very sick patient. We now need to formulate a working diagnosis (besides Diabetic Foot Ulcer) and a treatment plan. The following points need to be considered for this, as in any similar case presentation:
- What is the diagnosis?
- What further labs or studies do I need to fully assess the problem?
- How acute/urgent is this problem?
- Is hospitalization required? – or – Can I treat as an outpatient? If so, how?
- Are antibiotics required? If so, which one(s) and by what route?
- What consultations are necessary?
- Is surgery necessary? If so, what needs to be done?
- What is the ambulatory status of the patient on presentation and can we reasonably expect to maintain the same ambulatory level?
Consider how you would approach such a patient presenting to your office or clinic, keeping the 8 points above in mind. We will discuss this further next month with a complete overview of our approach to this clinical scenario and the patient’s outcome.
We welcome your opinions, concerns, and suggestions. If you have an interesting case or a troubling circumstance that you would like to share with fellow PRESENT Diabetes members, please feel free to comment on eTalk.
Best regards,
Robert Frykberg, DPM, MPH
PRESENT Editor,
Diabetic Limb Salvage
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