Group C: TASK 1- Clinical Case Study

Case 1- Diabetic foot infection

LEARNING OBJECTIVES

After completing this case study, you should be able to:

• Recognize the signs and symptoms of diabetic foot infections and identify the risk factors and the most likely
pathogens associated with these infections.
• Recommend appropriate antimicrobial regimens for diabetic foot infections.
• Recommend appropriate home IV therapy and proper counselling to patients.
• Outline monitoring parameters for achievement of the desired pharmacotherapeutic outcomes and
prevention of adverse effects.
• Counsel diabetic patients about adequate blood glucose control as part of an overall plan for good foot
health.

PATIENT PRESENTATION

Chief Complaint (CC)

• The patient had an ingrown toe nail that became infected several weeks ago, and now the whole foot is
swollen.

History of Present Illness (HPI)

• JC is a 67-year-old Dravidian man, who presents to the Emergency Department (ED) complaining of a sore
and swollen foot. Three weeks ago, he noticed that his right great toe became swollen and red due to an
ingrown toenail. The patient tried to fix the nail with scissors and tweezers, but the swelling got worse, and
thick, foul-smelling drainage became noticeable approximately 2 weeks ago. The patient was visiting family in
Belgaum at the time and now has just returned home to Bangalore. History is per translation by a hospital
interpreter. The primary care physician is Dr Mahantesh at XYZ hospital.

Past Medical History (PMH)

• Type 2 DM × 18 years
• Hospitalized 2 months ago for Hyperosmolar hyperglycemic state (HHS)
• Left second toe amputation 1 year ago secondary to diabetic foot infection
• Hyperlipidemia
• Hypertension
• Chronic renal insufficiency

Family History (FH)

• Father is expired (56-year-old) secondary to MI, type 2 DM, HTN.
• Mother is expired secondary to breast cancer (41-year-old).
• One daughter, alive and well, 42-year-old

Social History
• The patient lives with his wife in Marathalli, Bangalore. He denies tobacco and illicit drug use; however, he
admits to a long history of drinking four to five beers per day. He admits to nonadherence with his
medications and glucometer.

Medication
• Lantus SoloStar 40 units once daily
 • Humalog KwikPen 12 units with each meal
• Metformin 1000 mg PO twice daily
• Aspirin 81 mg PO once daily
• Lisinopril 20 mg PO once daily
• Atorvastatin 40 mg PO daily

Allergy
• Sulfa—severe rash

Review Of System
• Negative except as noted in the HPI

Physical Examination

Gen
• Patient is a thin Dravidian man who appears very concerned about losing his foot.

Vital Signs
• BP 126/79, P 92, RR 20, T 38.4°C; Wt 60 kg, Ht 5′10″

Skin
• Warm, coarse, and very dry

Head, eyes, ears, nose, and throat (HEENT)

• PERRLA (Pupils equal, react to light and accommodation);
• EOMI (Extraocular movements (or muscles) intact);
• funduscopic exam is normal with absence of haemorrhages or exudates.
• TMs (Tympanic membranes) are clouded bilaterally but with no erythema or bulging.
• Oropharynx shows poor dentition but is otherwise unremarkable.

Neck/Lymph Nodes
• Neck is supple; normal thyroid; no JVD; no lymphadenopathy

Chest
• CTA(Clear to auscultation.)

CV
• RRR, normal S and S
1 2

Abd
• Distended, (+) BS, no guarding, no hepatosplenomegaly or masses felt

Ext
• 2+ edema with markedly diminished sensation of the right foot. Significant swelling and induration
extend from first metatarsal to midfoot (4 cm × 5 cm) consistent with cellulitis. Purulent foul-smelling
drainage expressed from great toe wound. Wound probe 2 cm deep. Pedal pulses present but
diminished. Normal range of motion. Poor nail care with some fungus and overgrown toenails.
 Neuro
• A&O (Alert and oriented);
• CN(Cranial nerve) intact.
• Motor system intact.
• Sensory system exam showed a decreased sensation to light touch of the lower extremities (both feet);
• intact upper body sensation.

Labs
Na 136 mEq/L Hgb 14.1 g/dL

K 3.6 mEq/L Hct 42.3%

3 3
Cl 98 mEq/L Plt 390 × 10 /mm

3 3
CO 24 mEq/L WBC 17.3 × 10 /mm
2

BUN 30 mg/dL PMNs 78%

SCr 2.4 mg/dL Lymphs 17%

Glu 323 mg/dL Monos 5%

A1C 11.8%

ESR 73 mm/h

X-Ray
• Right foot: There is soft tissue swelling from first metatarsal to midfoot consistent with cellulitis. No fluid
collection noted. No evidence of adjacent periosteal reactions or erosions to suggest radiographic evidence of
osteomyelitis. No definite subcutaneous air is evident. Presence of vascular calcifications.

Assessment
• Diabetic foot infection with significant cellulitis in a patient with poorly controlled diabetes mellitus.

Clinical Course
• On the day of admission, the patient went to surgery for I&D. Blood and tissue specimens were sent for
culture and sensitivity testing.
ASSIGNMENT QUESTIONs

Collect Information
1.a. What subjective and objective information indicates the presence of a diabetic foot
infection?
1.b. What additional information is needed to fully assess this patient’s diabetic foot
infection?

Assess the Information

2.a. Assess the severity of the diabetic foot infection based on the subjective and
objective information available.
2.b. Create a list of the patient’s drug therapy problems and prioritize them. Include
assessment of medication appropriateness, effectiveness, safety, and patient adherence.

Develop a Care Plan

3.a. What are the goals of pharmacotherapy in this case?
3.b. What nondrug therapies might be useful for this patient’s diabetic foot infection?
3.c. What feasible pharmacotherapeutic alternatives are available for the treatment of
diabetic foot infection?
3.d. What alternatives would be appropriate if the initial care plan for the infection fails
or cannot be used?

Implement the Care Plan

4.a. What information should be provided to the patient to enhance compliance, ensure
successful therapy, and minimize adverse effects?

Follow-up: Monitor and Evaluate

5.a. What clinical and laboratory parameters should be used to evaluate the therapy for
achievement of the desired therapeutic outcome and to detect or prevent adverse effects?

SELF-STUDY ASSIGNMENTS

1. Review in more detail different therapeutic options available for home IV therapy, including the antimicrobial agents suitable for use, types of
IV lines available, and contraindications to home IV therapy.

2. Outline the patient counseling you would provide for successful home IV therapy.

3. Describe how you would educate this diabetic patient about proper foot care to prevent further skin or tissue breakdown.