CASE WRITE UP - DIABETIC FOOT ULCER

Case History: Lower Limb [Cold Case]

NAME                                       : Mr B

AGE                                           : 56 year

GENDER                                   : Male

RACE                                        : Chinese

ADDRESS                                 : Muar

OCCUPATION                         : Farmer

DATE OF ADMISSION           : 31^st of March 2008

DATE OF EXAMINATION     : 3^rd of April 2008

HOSPITAL NO                         : 29731

CHIEF COMPLAINT

Patient presented with chief complaints of pain and ulceration at left 5^th toe for 7 days.

HISTORY OF PRESENTING ILLNESS

Patient is a known diabetic for 4 years. The pain was felt at the left 5^th toe 7 days, which was sudden in onset and continuous. There was no radiation of pain. The pain was initially mild and then later it progressively increase in intensity. The pain aggravated by walking and there was no relieving factors.

            Patient then noticed an ulceration at the lateral side of his left 5^th toe for 7 days, which was initially a size of a 5 cent coin and now has progress in size up to a 50 cent coin. There was also pus discharge, which amounted to ½ a spoon and it was foul smelling. The discharge was also blood tinged.

       There was no fever, no numbness, no loss of sensation, no colour changes of skin at site of pain, no joint pain, no paresis of distal muscles, no history of loss of consciousness, blurring of vision, loss of appetite, loss of weight, nausea and vomiting, chest pain, abdominal pain, muscle cramps, fatigability, polyurea, polydypsia, change in bowel and bladder habits.

        Patient was brought to the hospital by car and x-ray of the left ankle and chest x-ray in supine position was done. Patient’s left 5^th toe has been undergoing debridement of the ulcer and daily dressing.

PAST HISTORY

No similar history in the past. Patient is a known diabetic since 4 years ago and is not compliant to diabetic medication. No history of asthma, tuberculosis, hypertension, ischemic heart disease and malignancy. No drug allergies. No surgical procedures done before.

FAMILY HISTORY

No similar history in the family. There was no history of diabetes, tuberculosis, asthma, hypertension and malignancy.

PERSONAL HISTORY

Patient’s sleep is normal. He has good appetite and does not control his diet as advised by the doctor. He has no known history of food or drug allergies. He does smoke about 10 sticks per day for the last 24 years. Patient does consume alcohol occasionally, about twice a month. No history of drug abuse. Bowel and bladder habits are normal.

SOCIAL HISTORY

Apparently, patient is living with his wife and two children in a village house with 4 rooms and 2 toilet of squatting type. His income is about RM1200 per month. The distance from the hospital is around 15 minutes by car.

Working Diagnosis

1. Infected diabetic ulcer of the left 5^th toe.

Reasons: There is pain and an ulcer on the left 5^th toe, discharging pus, and foul smelling. Patient is also a known diabetic for 4 years with no control of diet and medication.

2. Diabetic gangrene of the left 5^th toe.

Reason: There is an ulcerative growth at left 5^th toe which is progressively increasing in size with foul smelling pus discharge.

EXAMINATION

GENERAL PHYSICAL EXAMINATION

Patient is conscious, alert, and co-operative. He is moderately build and moderately nourished, comfortable in lying down supine position. There is an 20 gauge stopped intravenous cannular inserted on his right dorsum of his wrist. There is a plaster with cotton bandage on his left 5^th toe.

            There is no pallor, clubbing, icterus, cyanosis, oedema, or generalized lymphadenopathy seen.

There is discoloration (darker) seen on his left foot from his ankle joint until his toes. Head to toe examination is normal.

VITALS SIGNS

Pulse                       : 82 beats/minute, regular rhythm, normal volume, no special

         characters and all peripheral pulses in the existing limbs felt.  

Blood pressure       :136/84 mmhg measure on right arm on supine  position. 

Respiratory rate     : 20 breaths per minute.

Temperature          : 37 ⁰C

SYSTEMIC EXAMINATION

Cardiovascular Examination:

S1, S2 heard, no murmurs heard.

Respiratory Examination:

Vesicular breathing heard with no added sounds.

Abdominal Examination:

No abdominal tenderness, no organomegaly.

Central Nervous System Examination:

All reflexes elicited. No motor or sensory deficit.

LOCAL EXAMINATION

INSPECTION

There is bandage at the left 5^th toe.

Gait is normal.

Anterior superior iliac spines of both sides are at the same level.

Attitude  -left hip joint is abducted by 10⁰  and externally rotated by 10⁰.

               -left knee joint is neutral.

               -left ankle joint is plantar flexion 20⁰.

               -right hip joint is neutral.

               -right knee joint is neutral.

               -right ankle joint is neutral.

Deformity

            -There is an ulcer at the lateral side of the left 5^th toe.

Ulcer

            Site - lateral side of the left 5^th toe.

            Size - 3 x 3 cm, not extending to the bone, single ulcer.

            Shape - round.

            Surrounding skin - hyper pigmented (darkish red in colour). 

            Margin - regular.

            Edge - sloping edge.

            Floor - slough is pale and yellowish.

                      - Serous discharge, foul smelling.

                      - Bone is not exposed.

            Trophic changes - skin shiny, dry, scaly, loss of skin turgor.

            No limb deformity.

There is no other wound, no scars, no sinus, and no bleeding seen over the foot.

There is no limb shortening or lengthening.

             

PALPATION

Ulcer

No local rise of temperature.

Tenderness felt at the tip of the 5^th toe on the plantar surface.

Base – firm.

There is no bony irregularity felt along the tarsal bones, no abnormal mobility or crepitus. There is no loss of sensation distal to the site of ulceration.

MOVEMENT

Movements	Left		Right
	Active	Passive	Active	Passive
Hip joint
Flexion	0 - 130 º	0 - 130 º	0 - 130 º	0 - 130 º
Extension	0 - 20 º	0 - 20 º	0 - 20 º	0 - 20 º
Abduction	0 - 40 º	0 - 40 º	0 - 40 º	0 - 40 º
Adduction	0 - 20 º	0 - 20 º	0 - 20 º	0 - 20 º
External Rotation	0 - 45 º	0 - 45 º	0 - 45 º	0 - 45 º
Internal Rotation	0 - 30 º	0 - 30 º	0 - 30 º	0 - 30 º
Knee joint
Flexion	0 - 130 º	0 - 130 º	0 - 130 º	0 - 130 º
Extension	0	0	0	0
Ankle joint
Dorsiflexion	0 - 30 º	0 - 30 º	0 - 30 º	0 -30 º
Plantar flexion	0 - 45 º	0 - 45 º	0 - 45 º	0 -45 º
Subtallar joint
Inversion	0 - 40 º	0 - 40 º	0 - 40 º	0 - 40 º
Eversion	0 - 40 º	0 - 40 º	0 - 40 º	0 - 40 º
Movement of toes	Full range	Full range	Full range	Full range

MEASUREMENT

Measurements	Right	Left
Apparent length (xiphisternum to medial malleolus	122cm	122cm
True length (Anterior Superior iliac spine to medial malleolus)	94cm	94cm
Femur length (Anterior Superior iliac spine to medial joint line)	58cm	58cm
Tibial length (Medial joint line to medial malleolus)	36cm	36cm
Thigh circumference	52.5cm	52.5cm

Distal neurological status

There is no distal neurological deficit. Vibration and touch sensation can be appreciated by the patient. Full range of movements of toes present and there is no loss of sensation of the foot.

Distal vascular status

There is no distal vascular deficit. Dorsalis pedis artery and Posterior tibial artery could be felt and there is no distal limb coldness and capillary filling time is less than 3 seconds on both foot.

PROVISIONAL Diagnosis

1. Infected diabetic ulcer of the left 5^th toe.

Reasons: There is a pain and ulcer on the left 5^th toe, discharging pus, and foul smelling. Patient is also a known diabetic for 4 years with no control of diet and medication. The ulcer has a sloping edge with trophic changes of the skin.

 Investigations

  COAGULATION STUDIES:

PT	13.4
INR	1.16
APTT	34.6

 FULL BLOOD COUNT

Hb	12.1 g/dl
TRBC	2.9 X 10  /ml
PCV	27.2%
MCV	92.8fl
MCH	32.1pg
MCHC	31.6pg
PLATELETS	49% x 10 ul
TWBC	25.1x 10  ul
NEUTROPHILS	82.0%
LYMPHOCYTES	14.3%

                             

 ABG

Ph	7.358
Pco2	26.2mmhg
Po2	102mmhg
Hco3	14.7mmol/l
BE(B)	9.1mmol/l
O2 saturation	97.8%

              

 Swab of the ulcer for culture and sensitivity.

Final Diagnosis

Infected diabetic ulcer of the left 5^th toe.

Reasons: There is a pain and ulcer on the left 5^th toe, discharging pus, and foul smelling. Patient is also a known diabetic for 4 years with no control of diet and medication. The ulcer has a sloping edge with trophic changes of the skin.