CC: Diabetic foot infection in left foot. HPI: Patient has had uncontrolled type 2 diabetes for over 10 years. Presents today with a new diabetic foot ulcer that is infected.
CC: Diabetic foot infection in left foot.
HPI: Patient has had uncontrolled type 2 diabetes for over 10 years. Presents today with a new diabetic foot ulcer that is infected. Has previously had diabetic leg ulcers taking months to heal and needed wound care management, diabetic polyneuropathy, recent MI with stent placement d/t uncontrolled diabetes, and diabetic retinopathy.
PMH: Uncontrolled, Type 2 DM with long-term insulin use, Persistent hyperglycemia with A1C’s >9 %, Diabetic polyneuropathy secondary to uncontrolled diabetes, HTN, CAD s/p PCI, venous insufficiency, venous stasis ulcer, mixed hyperlipidemia, cellulitis of abd wall, fibromyalgia, RLS, Dyslipidemia, CR-T pacemaker placed 7/20, cellulitis, MRSA carrier, Glaucoma, Anemia, and anxiety, depression, diabetic retinopathy. (Feel free to keep diagnoses relevant to this case study)
Current medications: Trulicity 4.5, Lantus 40 units BID, aggressive Humalog sliding scale 16-30 units based on finger stick blood sugar prior to meals.
Allergies: Metformin, Vanc, sulfa
Social: Patient has a lot of stress in her life. Her husband has had 3 strokes in the past year and requires a lot of care, but is able to be home alone in the day time when she works, but she worries about him constantly when she is at work. She has a hard time affording their medication and bills, which adds constant stress.
Reports having to make hard decisions sometimes and can’t get all prescribed medications for both her and her husband. Reports being stressed about having to leave work for doctor’s appointments. Her pcp doctor has involved a health coach, dietician, and pharmacist in her treatment plan for added support, but no change in A1C levels. Patient feels more stressed because they are all telling her different things to do. Additionally, she receives medication for anxiety and depression.
PE: Appears highly stressed, anxious, and defeated. Expresses frustration that despite her efforts, she isn’t getting better. Stating she can’t go to all the specialists she’s been referred to because she can’t afford it and can’t drive 45 minutes for the visits.
DX: Persistent hyperglycemia/uncontrolled type 2 diabetes
Differential DX’s: cortisol dysregulation, chronic stress leading to acute phase response leading to inflammation, or medication malabsorption (should she be using concentrated insulin like U-300 glargine or U-500 regular insulin, because they facilitate improved insulin absorption). (This can be altered based on what article you find, but looking for something similar).
Clinical question: Does prescribing medications for anxiety and depression reduce A1C levels in patients with persistent hyperglycemia, who are already taking a GLP-1 receptor agonist and insulin? (This can be changed, but this is the kind of question, I’m looking for).
Foot infections are common in patients with diabetes and are associated with high morbidity and risk of lower extremity amputation. Diabetic foot infections are classified as mild, moderate, or severe.
Gram-positive bacteria, such as Staphylococcus aureus and beta-hemolytic streptococci, are the most common pathogens in previously untreated mild and moderate infection. Severe, chronic, or previously treated infections are often polymicrobial.
The diagnosis of diabetic foot infection is based on the clinical signs and symptoms of local inflammation. Infected wounds should be cultured after debridement.
Tissue specimens obtained by scraping the base of the ulcer with a scalpel or by wound or bone biopsy are strongly preferred to wound swabs. Imaging studies are indicated for suspected deep soft tissue purulent collections or osteomyelitis.
Optimal management requires aggressive surgical debridement and wound management, effective antibiotic therapy, and correction of metabolic abnormalities (mainly hyperglycemia and arterial insufficiency). Treatment with antibiotics is not required for noninfected ulcers.
Mild soft tissue infection can be treated effectively with oral antibiotics, including dicloxacillin, cephalexin, and clindamycin. Severe soft tissue infection can be initially treated intravenously with ciprofloxacin plus clindamycin; piperacillin/tazobactam; or imipenem/cilastatin.
The risk of methicillin-resistant S. aureus infection should be considered when choosing a regimen. Antibiotic treatment should last from one to four weeks for soft tissue infection and six to 12 weeks for osteomyelitis and should be followed by culture-guided definitive therapy.