Chief’s Morning ReportJuly 11, 2011

O Disclaimer: There are graphic pictures to keep the attention of the audience.

HPIO 43 yo male with h/o DM,

Schizophrenia brought in after family called police due to patient not caring for foot ulcer. Ulcer had been present 6 months after trauma. Pt and his brother had been self caring for wound at home. Pt denied fevers, chills, drainage, pain.

O PMH: as aboveO PSH: L calf I&DO FH: DM (mother)O Social: lives with mother

(bedbound), brothers; no TEDO Meds: none for 5 yearsO Allergies: NKDA

Physical ExamVitals: AF, HR 100, BP 156/96, SaO2 96%, 18

General: alert, oriented, NADHEENT: PERRLA, EOMICV: regular rhythm, normal rate, no murmursPulm: BCTA, no wheezing or cracklesAbdomen: soft, NTND, + BSExtremities: BLE decreased sensation to light touch, vibration, pain; L foot with erythema, edema over 5th digit with small 1cm wound over plantar aspect probed to bone; 1+ pulses

Questions:O What puts this patient at risk for

infection and complications?O How can you tell if his foot is

infected?O If this is infected, what organisms

are you concerned about?O What should you do/order next in the

management of this patient?

Guidelines for the Diagnosis and Treatment of Diabetic Foot

InfectionsA diabetic foot infection is any inframalleolar

infection in a diabetic patient including paronychia, cellulitis, myositis, abscess, necrotizing fascitis,

septic arthritis, tendonitis and osteomyelitis.

What puts this patient at risk for infection and complications?

Neuropathic Ulceration

Teelucksingh S, Naraynsingh V. N Engl J Med 2010;362:e26.

Infected?

If his foot is infected, what organisms are you concerned about?

What should you do/order next?

O CBC 9.1>9.6/28.9<508O CRP 14.9, ESR 60O HbA1C 10.5O Plain filmsO Blood cultures: negativeO Wound cultures: not done

Hernandez, Miguel GHernandez, Miguel G001412020014120211/5/196711/5/196743 YEAR43 YEARMM

Page: 1 of 3Page: 1 of 3

University Health Systems University Health SystemsXR FOOT 3 OR MORE VIEWS 73630XR FOOT 3 OR MORE VIEWS 73630

Foot apFoot ap 3/25/2011 3:40:50 PM 3/25/2011 3:40:50 PM

3068206730682067------------------

IM: 1IM: 1Compressed 27:1Compressed 27:1

W: 4095W: 4095C: 2047C: 2047Z: 0.42Z: 0.42S: 320S: 320

cm cm

Hernandez, Miguel GHernandez, Miguel G001412020014120211/5/196711/5/196743 YEAR43 YEARMM

Page: 2 of 3Page: 2 of 3

University Health Systems University Health SystemsXR FOOT 3 OR MORE VIEWS 73630XR FOOT 3 OR MORE VIEWS 73630

Foot obliqueFoot oblique 3/25/2011 3:41:41 PM 3/25/2011 3:41:41 PM

3068206730682067------------------

IM: 1IM: 1Compressed 27:1Compressed 27:1

W: 4095W: 4095C: 2047C: 2047Z: 0.45Z: 0.45S: 320S: 320

cm cm

Hernandez, Miguel GHernandez, Miguel G001412020014120211/5/196711/5/196743 YEAR43 YEARMM

Page: 2 of 3Page: 2 of 3

University Health Systems University Health SystemsXR FOOT 3 OR MORE VIEWS 73630XR FOOT 3 OR MORE VIEWS 73630

Foot obliqueFoot oblique 3/25/2011 3:41:41 PM 3/25/2011 3:41:41 PM

3068206730682067------------------

IM: 1IM: 1Compressed 27:1Compressed 27:1

W: 4095W: 4095C: 2047C: 2047Z: 0.45Z: 0.45S: 320S: 320

cm cm

Hernandez, Miguel GHernandez, Miguel G001412020014120211/5/196711/5/196743 YEAR43 YEARMM

Page: 2 of 3Page: 2 of 3

University Health Systems University Health SystemsXR FOOT 3 OR MORE VIEWS 73630XR FOOT 3 OR MORE VIEWS 73630

Foot obliqueFoot oblique 3/25/2011 3:41:41 PM 3/25/2011 3:41:41 PM

3068206730682067------------------

IM: 1IM: 1Compressed 27:1Compressed 27:1

W: 4095W: 4095C: 2047C: 2047Z: 0.45Z: 0.45S: 320S: 320

cm cm

Three views of the foot demonstrate severe osteolysis/destruction of the fifth metatarsal head and fifth digit P1 segment with osseous fragmentation noted in the region. Findings are complatible with osteomyelitis and septic arthritis. Severe surrounding soft tissue swelling is noted. No definitive soft tissue gas is seen. There is periosteal reaction along the lateral margin of the fifth metatarsal proximal diaphysis also concerning for early osteomyelitis. Loss of the cortex along with plantar aspect of the fourth metatarsal head is also concerning for osteomyelitis. Cortical thickening along the lateral margin of the fourth metatarsal diaphysis may be reactive.

How are you going to treat?

What if they are not responding to treatment?

More treatment

How long are you going to treat?

Follow-upO Daily for inpatientsO Initially every 2-5 days for

outpatients

Osteomyelitis suspected

PreventionO A patient that has had one infection

is more likely to have another.O Detection of neuropathy before

complicationsO Educate on importance of glycemic

control, appropriate footwear, avoidance of trauma and daily foot examinations.

O Reinforce these measures at appointments with questioning and regular examinations.

ReferencesO Lipsky,Berendt, Deery, Embil, Joseph,

Karchmer,LeFrock,Lew, Mader, Norden, Tan. Diagnosis and Treatment of Diabetic Foot Infections. Clinical Infectious Diseases 2004; 39:885–910.

O Pinzur MS, Slovenkai MP, Trepman E, Shields NN. Guidelines for diabetic foot care: recommendations endorsed by the Diabetes Committee of the American Orthopaedic Foot and Ankle Society. Foot Ankle Int. 2005 Jan;26(1):113-9.

Questions?