CHIEF COMPLAINT: Pain Right Foot

HISTORY: The patient is a (XX)-year-old Hispanic female who presented to the emergency
department complaining of pain in her right foot as well as redness and swelling x3 days. She
was found to have a blood sugar of 430 and was subsequently admitted for hyperglycemia.
Podiatry was consulted for the right interdigital ulcer and overlying cellulitis. She notes that the
foot had only been red and slightly swollen for the last 2 to 3 days, and it was only recently that
she even knew she had a wound in between her toes. She denies any fever, chills, nausea, or
vomiting. To her knowledge, she cannot remember any kind of drainage from the ulcer on the
right fourth toe. She states that there is some burning sensation to palpation over the toe wound.

PHYSICAL EXAM:  Vital Signs: Temperature 98.6 degrees, pulse 104, respirations 20, and
blood pressure 200/96. Dorsalis pedis and posterior tibial pulses are nonpalpable bilaterally.
Using Doppler ultrasound, the posterior tibial pulses are audible. However, the dorsalis pedis is
not audible in the bilateral lower extremities. There is erythema noted to the right forefoot and is
most pronounced in the digits 1 and 4. Proximal streaking is noted extending from the dorsal
surface near the fourth interspace extending proximally over the foot and also is located at the
lateral aspect of the fourth digit on the right foot. The ulcer measures approximately 1 cm x 1 cm
in size; has a dark, dry fibrotic base with surrounding macerated borders. There is no drainage,
no malodor appreciated. Skin is cool to the touch. Sensation is diminished in the bilateral lower
extremities. Muscle strength is within normal limits.
LABORATORY DATA:  WBC 16.4, hemoglobin 14.2, hematocrit 41.6, and platelets 342,000.
Sodium 136, potassium 4.2, chloride 102, CO2 of 24, BUN 18, creatinine 0.9, and glucose 280.
Wound culture of the right fourth digital ulcer, 3+ gram-positive cocci, 1+ gram-positive rods.
Blood cultures x2 pending at this time. Urine culture, 3+ bacteria.
RADIOLOGICAL DATA:  Three views of the right foot, no soft tissue emphysema, no
fractures or dislocation. No evidence of osteomyelitis.
ASSESSMENT:
1.  Right foot ulcer with cellulitis/lymphangitis.
2.  Diabetes mellitus.
3.  Hypertension.
4.  Urinary tract infection.
PLAN:  At this time, continue IV antibiotics until further recommendations are made by
Infectious Disease. We will order serial Dopplers, bilateral lower extremities. The patient has
been advised to keep the right leg elevated when at rest and to minimize weightbearing as much
as possible on the right leg. Further recommendations to follow.