clinical vise assignment week 4

Right Great Toe Diabetic Foot Infection

Summary

Pt AE is a 39 years old white male with NKA allergies and PMH including tobacco use, HTN, new diagnoses of Diabetes type II, GERD, hyperlipidemia, Gout, Mobid Obesity, peripheral vascular disease (PVD) and neuropathy. Pt takes amlodipine 5 mg daily, he denies taking his prescribed atorvastatin due increasing in joint pain. AE only takes OTC ibuprofen 250 mg TID for pain. Pt works full time on his own company, AE his own artificial grass company and works from home.

1. Chief Complaint

The patient complains pain in his right great toe.

2. History of present illness

Onset

The patient identified the foot infection 2 days ago. The patient began feeling pain in his right big toe

Location

The infection is in the patient’s right great toe.

Duration

Right great toe pain is continuously and burning comes, goes, and lasts for an average of 3 to 5 minutes.

Characteristics

Sharp and burning pain, tingling sensation, numbness in the right great toe, change in skin color, redness, heat, and tenderness, pain radiates to his right lower leg.

The patient does not have a history of the a right great toe infection

Aggravating factors

Aggravating factors for the pain in the right great toe is when the patient walks for too long, or the patient walks uphill, or put weight on right foot.

Relieving factors.

Pain is relieved when the patient takes a rest, or lies down.

Treatment: currently only takin OTC ibuprofen 250 mg PO for moderate pain TID

When identifying the history of the present illness it is vital to focus on indications of possible peripheral arterial insufficiency or peripheral neuropathy. Patients with peripheral neuropathy have symptoms like hypoesthesia, hyperesthesia, dysesthesia, anhydrosis, and radicular pain (Khardori et al, 2020). The onset of the diabetic foot infection

3. Subjective and objective findings relevant to the case

The patient complains of a pain in his right great toe. The subjective findings in the patient are outlined as follows. The patient indicates that there is a burning, numbness, heat, and tingling sensation on the affected part. The objective findings include symptoms emanating from the right foot of the patient are a change in skin color (Benjamin n.d.).

4. Brief and concise summary

Patients with diabetic problems face a higher risk of foot infections and health problems. Conducting a diabetic foot exam helps identify foot infections, bone abnormalities, and injury. Diabetic foot infections are mostly attributed to neuropathy or poor blood circulation to the feet. The poor blood circulation in the foot makes it hard to heal ulcers, or other injuries in the foot leading to an infection that could be severe. Following a foot exam frequently along with home care is essential in preventing serious foot infections in diabetic patients. The diabetic foot exam will allow for the early identification of foot health problems for treatment. A diabetic foot exam is imminent once the patient experiences symptoms like tingling, numbness, swelling, pain, difficultly in walking, and burning sensation (Khardori et al, 2020).

Appropriate management plan

1. How the student confirmed or established the diagnosis

Physical examination of the patient

The physical exam can be divided into three categories i.e.

1. Examining the ulcer/infection and the general condition of the extremity. This step involves assessing the foot areas most susceptible to weight bearing e.g. big toe. This physical exam can help locate brittle nails, hammer toes, or fissures.

2. Assessing possible vascular insufficiency (PVD). Helps to locate diminished peripheral pulses down a certain level. +2 femoral, popliteal, dorsalis pulses and posterior tibia pulses, bilaterally capillary refill less than 3 seconds, pressure ulcer in the right great toe measurements are: 4 cmx 3.2cm x 0.5 cm, malodorous. Pt had a normal ROM in bilateral extremities, erythema and swelling in the great toe with moderate purulent drainage, slough note in the wound bed, and great toe is hot to touch. Pt reports decrease sensation in bilateral lower extremities and increase and burning and tingling at night, neuropathy has impacted AE’s sleep pattern and sports (AE plays golf on Friday & Saturday)

3. Assessing possible peripheral neuropathy. Symptoms of peripheral neuropathy include loss of position and vibratory sense, foot drop, among others.

This evaluation should also include the following diagnostic test and laboratory test such as

· Assess infection severity

· Plan for radiographs ( CT and MRI to identify depth of the infection and rule out osteomyelitis) of the foot

· Wound culture needed

· CBC , Chemistry 7 and A1C (Assess renal function BUN and Creatinine)

· Review comorbid conditions of the patient.

Differential diagnosis linked to the Chief Complaint

It is important to distinguish diabetic neuropathy from other kinds of neuropathy like vasculitic neuropathy, metabolic neuropathy, or radiculopathy etc.

Differential diagnosis include

1. Diabetic foot infection ( cellulitis)

2. Atherosclerosis/ PAD

3. Chronic venous insufficiency.

Use key positive and negative findings to argue for a diagnosis

Atherosclerosis occurs once blood vessels thicken preventing the transfer of oxygen and nutrients to all parts of the body. Symptoms of atherosclerosis in the arms and legs include peripheral artery disease. The characteristics include pain in the legs as the patient walks. Chronic venous insufficiency on the other hand occurs to the patient once the veins in the patient’s legs are not working effectively. Hence, blood circulation in the legs is deficient. Symptoms related to chronic venous insufficiency include aching in the legs, swelling of the legs, itching skin on the feet and legs.

Other differential diagnosis might include squamous cell carcinoma, superficial thrombophlebitis, and vibrio vulnificus infection.

My differential diagnosis of choice is Diabetic foot infection. Foot infections are not limited to diabetic infections alone. It is important to avail all other possible infections. Differential diagnosis of cellulitis include leukoclastic angitis, diabetic dermopathy, and superficial thrombophlebitis.

Confirming diabetic foot infection is reliant on clinical diagnosis as opposed to bacteriological diagnosis. A positive clinical diagnosis for diabetic foot infection is characterized by purulent discharge from the infection and classical signs like pain, tenderness, and erythema all related to inflammation, foul odor, necrosis, and failure of wound healing (Mazen S et al, 2008).

2. Medications i.e. chosen OTC or RX

The medication plan for non-hospitalized patients includes.

· Probing and debriding the wound/infection

· Obtain an appropriate infection specimen for culture.

· Prescribe the appropriate wound care regimen

· Antimicrobial regimen ciprofloxacin 750 mg PO Q12 hours and clindamycin 300-450 mg PO Q6.

Upon diagnosis medication for a hospitalized patient include

· Medically stabilizing the patient

· Surgical procedures i.e. podiatric or vascular

· Conducting appropriate imaging like XRAY, CT scans, MRI.

· Re-evaluation of the patient on 5 days

Wound and foot care includes topical wound management and care. Medication includes wound healing agents like Penicillin, tramadol for pain management, Dakin solution for management and care of pressure ulcer and medi honey.

3. Patient education given

Patient education for diabetic foot infected patients include cutting nails carefully, inspecting feet daily, bathing feet in lukewarm water, wearing clean and dry socks, and adhering to foot exams (Bader, 2008).

4. Follow-up instructions

This involves careful observation of the patient’s response to therapy. Observation should be performed daily for hospitalized patients and within 2-5 days for outpatients. Indicators of improvement include

· Resolution of inflammation, and local symptoms.

The follow up plan includes re-evaluating the infection, setting up definitive antibiotic regimens, and evaluating glycemic control (Richard, et al, 2011).

5. Consideration to cost, availability, or patient preference

Recheck patient’s medical history to identify other complications that could hinder medication for diabetic foot infection. The patient has a medical history of Diabetes type II, GERD, hypertension, hyperlipidemia, Gout, Morbid Obesity, peripheral vascular disease.