!

Department of Orthopaedic
Cyberjaya University College of Medical
Sciences
EBM

Infected diabetic ulcer of the left 3

Name :Sana Anam

Group: Group 02 (2012/2013)

Matric No: MBBS 1411-5971

Supervisor:Assoc. Prof.Dr.Zairul Nizam

Patient's Data
Name: Faridah binti Ahmad Azman

Age: 55 years Old

Sex : Female

Location: Hospital Serdang,

History
Chief Complain

The patient, Faridah binti Ahmad Azman is a 55 year old Malay lady with underlaying uncontrolled Diabetes
mellitus on combination therapy. under follow up in Klinik Kesihatan Puchong, for past 7 years was presented with pain
and swelling at distal 2/3 of left 3th toe for past 7 days.

History of Presenting Illness

The patient was apparently well until 7 days prior to admission, Patient experience progressive pain over the
left 3rd toe, the pain was throbbing in nature, progressive in intensity, not radiating, the pain was aggravated by
walking, their was no relieving factor. the pain score was 7/ 10. Patient does not have any history of trauma, burn or
insect bite. Patient also the noticed initial there was a swelling over the skin of left 3rd toe associated with redness and
later had loss of structure at the lateral side of his left 3rd toe on 3rd 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 about to a spoon and it
was foul smelling. The discharge was also have blood tinged. She also have low grade fever which was intermittent in
nature, resoled with Paracetamol temporarily,
otherwise there was no chills and rigour, no vomiting, no loss diarrhea. over the side of swelling there was no
numbness, no joint pain, no paresis of distal muscles, no history of loss of consciousness, blurring of vision, no nausea
and vomiting but patient have experience increase in of appetite, despite loss of weight about 10 kg in past one month,
patient also experience fatiguability, polyuria, and polydipsia.
Review of System
Dermatologic: lost of skin structure (ulceration), however no sores or joint pains.
Cardiovascular: no palpitations, syncope, or orthopnea
Gastrointestinal: no nausea, vomiting, or changes in bowel movement
Genitourinary: increase in urination. no change in urine colour.
Past Medical History
This is Patient first hospitalisation, there no similar episode before, otherwise she is a known case of diabetic
for past 7 years, and she is not compliant to diabetic medication as her last HbA1c 9, and fasting Blood glucose was 13
and not on diet control. otherwise patient does not any history of asthma, tuberculosis, hypertension, ischemic heart
disease and malignancy. There is no drug or food allergy. Patient is not taking any kind supplements. No surgical
procedures done before
Family History
There is no history of diabetes , asthma ,malignancy, or any chronic illnesses in the Patient family
Social History
Apparently, patient is living a sedentary life . She is married and living with her husband and her son who is working as
engineer, They are staying in double story semi-D house in pouching which has 3 rooms and 2 toilet of squatting type.
She is a housewife and her husband is a retired government servant with income is about RM1500 per month. The
distance from the hospital is around 20 minutes by car. she is a non-smoker and have no history of consuming alcohol.

Physical Examination
General inspection

Patient is conscious, alert, and co-operative. She is moderately build and moderately nourished, comfortable in lying
down supine position. their is an Intravenous barnula attach at the left dorsum of the left hand. There is a plaster with
cotton bandage on his left 3rd toe. There is no pallor, clubbing, icterus, cyanosis, oedema, or generalised
lymphadenopathy seen. There is discoloration (darker) seen on his left foot from his ankle joint until his toes.
Vital signs
: 37.0C
o Temperature
o Blood Pressure : 120/80 mmHg measure on right arm on supine position.
o Respiratory Rate ; 24 breaths/minute
o Pulse Rate
: 82 beats/minute, regular rhythm, normal volume, no special characters and all
peripheral pulses in the existing limbs felt.
Neck and face examination
: Acteric sclerae, pink conjunctivae, no distended neck veins

Cardiopulmonary

: Symmetric and equal chest expansion,clear breath sounds,no crackles, no

wheezes, adynamic precordium, no heaves, no thrills.
The apex beat at 5th ICS mid-clavicular line, normal rate and regular rhythm
with good and distinct S1 and S2
: The abdomen was soft, flat and non-tender, bowel sounds present,
tympanitic in all quadrants, and their was no organomegaly.

Abdomen
Central Nervous
System Examination

: All reflexes elicited. No motor or sensory deficit.

Motor
: 5/5 right lower extremities; 5/5 left lower extremities,5/5 in both upper extremities.
Reflexes
: normel reflexes.
Cerebellar
: can do finger-to-nose test using the right arm; can do rapid alternating hand movement
. .(only the right arm)

Musculoskeletal Examination:
inspection (look)

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 distal 2/3 of the left 3rd toe

Ulcer

Site - more on lateral side of the left 3rd 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.

Palpation (Feel): Ulcer No local rise of temperature. tenderness felt at the tip of the 3rd toe on the lateral
side.
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.

Move:

o Range of Motion (Upper Extremities): WITHIN NORMAL LIMITS

DISTAL NEUROLOGICAL STATUS
There is no distal neurological deficit . however Vibration and touch sensation in reduce over the left foot until
the ankle level. Full range of movements of toes present and there is reduce 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.

Summary
My patient , Faridah binti Ahmad Azman a 55 year old Malay lady with underlying uncontrolled Diabetic
type 2 on irregular medical treatment for past 7 years, was presented with progressive pain, fever and ulceration at distal
side of left 3rd toe for past 7 days, General condition was good. Pulse 82/ minute. Local examination of left foot
revealed ulceration with trophic changes of the skin, foul smelling discharge and pus. she have signs of neuropathy over
the left foot where reduce sensation, Distal pulsations were present. The systemic review is unremarkable.

Provisional Diagnosis:

Infected diabetic ulcer of the left 3rd toe.

There is a pain and ulcer on the left 3rd toe., discharging pus, and foul smelling. Patient is also a known
diabetic for 7 years with no control of diet and medication. The ulcer has a sloping edge with trophic changes
of the skin.

Investigations
Full Blood Count (FBC)

Hb;12 ,MCV; 38 , WBC: 18 , N:85 , Pllt; 250

Fasting Blood glucose

12

Blood Culture and sensitive

polymicrobial

Renal Profile

U: 4.9 ,Na: 136, K;3.8, Ch:98 ,Cr;89

X-ray of left foot.

No Bone changes

Definitive Diagnosis
Infected diabetic ulcer of the left 3rd toe.
There is a pain and ulcer on the left 3rd toe, associated with intermittent fever, discharging pus, and
foul smelling. Patient is also a known diabetic for 7 years with no control of diet and medication.
The ulcer has a sloping edge with trophic changes of the skin. Full blood count also appear
infection.

Management

admite patient to ward.

stabilising the patient vital signs;
Hydrate the patient With IV Normal Saline fluid maintenance.
Pain management start patient on T. Paracetamol 1g qidor NAID Tramaldol 50mg tds.
IV broad spectrum antibiotics Unasyn 1.5g TDS
wound debridement.
Start patient on Sliding scale to monitor Glucose level.
Daily Wound dressing and limb assessment.
Patient was suggested to have lifestyle modification and Diabetic foot care. Further more patient
have to go for daily wound care.

EBM
1) What are the aspect of management of Diabetes wound.
My patient had been diagnose type 2 diabetes for past 7 years, and according to patient she is not compliant
to his medication. During history taking patient presented with uncontrolled diabetes as he have polyuria,
polydipsia , as well as significant weight lost. Patient presented with a painful 3rd left toe ulcer. and the over
laying skin of left toe appear to be dry, and hyper pigmented. Diabetic foot ulcer have a multifactorial nature.
as this patient have insulin deficiency is the basis of the biochemical abnormalities that lead to the organic
complications of diabetes mellitus. Diabetic foot ulcer result from a complex interaction of two major risk
factors: neuropathy and peripheral vascular disease.
Base on to the Scottish Intercollegiate Guidelines Network, Management of diabetes
wound required environment which will promote healing, and should be promoted through avoidance of
dehydration assessment of hydration status as well as start patient on IV fluids therapy in case condition of
dehydration, avoid cold, stress and pain where by give adequate amount of analgesia such as paracetamol,
NSAIDs required close monitoring of dose, and according to assessment of patient pain score. The
immediate management one patient is stabilised are wound debridement to remove necrotic and devitalised
tissue which will promote tissue healing and stimulate tissue growth improve healing proses.
Furthermore cultured and sensitivity of the affected skin is required to identify the most affective antibiotic
therapy for the most probable organism causing the infection. in some patient can be benefit in healing
diabetic foot ulcers by topical antimicrobial dressings may be beneficial when wounds are chronically or
heavily colonised.
The ulcer should be irrigated with a neutral, non-irritating solution, Normal saline, and cleansed with
minimal chemical or mechanical trauma. Daily dressing is required to provide and maintain a moist woundhealing environment (except where dry gangrene or eschar is present), manage wound exudate and protect
peri-ulcer skin, Treatment should be re-evaluated when there is failure to achieve ulcer size reduction of 40%
after 4 weeks of therapy. One of the most important aspect of management is Optimising glucose control
improves wound healing, sliding scale in ward is required to monitor and to achieve therapeutically optimum
glucose control, additional therapy may be helpful, as follows topical negative pressure wound therapy
promotes healing of diabetic wounds, hyperbaric oxygen therapy reduces risk of amputation in patients with
ischemic diabetic foot ulcers.
According Gregory Weir, if the wound does not respond to conservative therapy, intervention and adjuvant
options should be considered. The rationale for resecting a chronic ulcer
and its base is that a chronic wound will be replaced by an acute one which will proceed
to heal at an increased rate. Moreover, if the process of resection includes the removal of bone underlying
ulcers in areas subjected to abnormal pressure loading (such as under the metatarsal heads), then healing may
be enhanced by the offloading which results. Excision of plantar ulcers with or without removal of
underlying bone There is evidence to support complete excision of plantar neuropathic ulcers. The resection
includes the entire wound bed, together with any underlying bony prominences. This is associated with faster
healing. According to a study done Braun LR many therapeutic modalities are available to treat DFU.
Quality high-level evidence exists for standard care such as off-loading. Evidence for adjunctive therapies
such as negative pressure wound therapy, skin substitutes, and platelet-derived growth factor can help guide
adjunctive care but limitations exist in terms of evidence quality.
Therefor Diabetic foot ulcers are extremely difficult to treat. they required Multidisciplinary management,
patient education, glucose control, debridement, offloading, infection control, and adequate perfusion are the
main issue of standard care endorsed by most practice guidelines. Adjunctive therapies represent new
treatment modalities endorsed in recent years, though many lack significant high-powered studies to support
their use as standard of care.

6. REFERENCES.
1. DIABETIC FOOT ULCER: AN EVIDENCE-BASED TREATMENT .Braun LR1, Fisk
WA, Lev-Tov H, Kirsner RS, Isseroff RR. 2014 Jul;15(3):267-81. doi: 10.1007/
s40257-014-0081-9.
2. Scottish Intercollegiate Guidelines Network, Management of diabetes. A national clinical
guideline. Edinburgh, Scotland: SIGN 2010.
3. CLINICAL PRACTICE GUIDELINES On Management of Diabetes Mellitus Type 2.
Malaysia 2004
4. National Evidence-Based Guideline on Prevention, Identifi cation and Management of Foot
Complications in Diabetes. Melbourne Australia 2011. http://t2dgr.bakeridi.edu.au/
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