A 64 yo obese female with a 10 year history of NIDDM (non-insulin dependent diab

Question

A 64 yo obese female with a 10 year history of NIDDM (non-insulin dependent diabetes mellitus) presents to the clinic with chief complaint of "a sore on the top of my foot". The patient states that the "sore" has been present for 2 weeks and that she has been " watching and cleaning it." The last 3 days, she has noted that her foot is becoming somewhat "red and warm". She also reports malaise and some "blurriness" in here vision. Presently, the patient is taking Metformin and has recently been placed on Humulin in the am because "her sugars were running high". She also takes Metoprolol for HTN. On examination, the BP is 142/94, temperature is 101 and a glucose reading is 326. There is a 2cm ulcer on the dorsal medial aspect of the L foot at the medial cuneiform with some " greenish discoloration". There is no other "drainage" from the area. The foot overall is mildly edematous with erythema (redness) of the skin surrounding the ulcer and extending over the dorsum of the foot. She is admitted to the hospital with a diagnosis of cellulitis of the L foot secondary to ulcer formation. 1) What aspect of the physical exam regarding this patient's foot is NOT reported, but needs to be known? _____ 2) Where in the hospital should this patient be admitted? 3) Before placing this patient on an antibiotic, the wound is_____ and the specimen sent for_____report. 4) What " blood studies" need to be done prior to therapy given the history above and the admitting diagnosis? 5) What 2 bacterial " strains" are most likely causing this wound infection? 6) What is causing the " greenish discoloration" of the ulcer?

Explanation / Answer

1. The aspects of the physical examination that should be reported are a. Pain b. Appearance of skin in relation to tightness or streched appearance and c. The rate of spread of skin rash-As a typical skin rash of cellulitis spreads rapidly within 24 hrs, the patient (since watching and cleaning the sore area) could tell her observation.

2. Patient must see a primary care or emergency care doctor at first. Hospitalization of the patient would necessarily be under infectious disease specialist. Consult of endocrinologist (for high sugar level) and cardiologist (HTN) needed.

3. Before putting the patient on antibiotic, the wound is specimened and the specimen is sent for culture. Wound culture is done before administring antibiotic as wound culture test reveal the microorganisms involved in wound infection. Direct and effective line of antibiotic treatment can then be given.

4. The blood studies required are

a. Complete Blood Count (CBC) - RBC, WBC count, HB etc

b. Basic Metabolic Panel (BMP) - Blood glusoce, electrolyte and acid-base balance

c. Blood culture

5. Bacterial starins that are most commonly inolved in wound infection are - a. Staphylococcus and b. Streptococcus.

6. Greenish discoloration of the ulcer may occur due to colonization of Pseudomonas.

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