Medicine

CLINICS
Case Presentation
MED 3 - Group 5
 History & PE
01
Diagnosis
02 Salient Features & Basis for
Differential Diagnosis Diagnosis
03
Diagnostics
04
Management
Pharmacological &
05
Nonpharmacological Mgt Concept Map
06
 01
History & PE
: Apr 6. 2011, 4:00 PM
Date & Time of Interview
tient & patient’s son
Source of Information: Pa
Reliability: 75%
Referral: None
 Patient’s GEN. DATA

77 year old, male, widowed,

Filipino, Roman Catholic Mr. Valeriano Anadia
Previous cigarette vendor
Currently unemployed.
Born in Abuyog, Leyte. Occupation and Address
Residing in Brgy. 43B Quarry,
Tacloban City

Admitted at EVMC on
April 1, 2022 at around Date of Admission
9:00 PM
“Nangitom an samad ha
may tamuragko.”
CHIEF COMPLAINT
HISTORY of Present Illness

6 YEARS PTA 2 MONTHS PTA

(2016)
5 YEARS PTA (2017)

Diagnosed with ● Wounded by thumbtack ● Frequent falls from his bed, often gets
Type 2 on the sole of right foot scratches from the rough floor while being
Diabetes (poor wound healing) barefoot
Mellitus ● Amputation of right leg ● Erythema, swelling, tenderness and pain
up until the knee (PRS: 5/10) on left foot that extended
almost to the knee
● Progressed to blister formation then later
on, with associated pus
 HISTORY of Present Illness

1 MONTH PTA 5 DAYS PTA

● Persistence of blister with pus on left leg Symptoms

● Eventually developed to a gangrenous area (initially on the big toe and persisted thus,
progressed to include the rest of the toes prompting consult
○ Left leg was no longer erythematous nor edematous and subsequently
○ Associated with fever (undocumented), loss of appetite, weight admitted
loss
● Foot symptoms aggravated by direct contact of foot to spit, urine and
feces on the floor near his bed
Past Medical History
Childhood Illnesses Chickenpox, mumps, measles

● Medical: Admitted in 2016 due to uncontrolled Type 2

Adult Illnesses DM at EVRMC Magsaysay; given 500 mg Metformin 2x
day upon discharge. Known hypertensive since March
2021; maintenance medication of Losartan 50 mg OD
● Surgical: Right leg amputation in 2017 at EVMC
Cabalawan
● Medications: 500 mg Vit C, Vit B complex. Maintenance
medication Metformin 500 mg TID, Losartan and
Amlodipine with unrecalled dosage. Currently given
Atorvastatin 40 mg OD (taken every 8pm). Poorly
compliant to medications up until admission.
Past Medical History
Psychiatric No psychiatric history or record

Unrecalled childhood immunization.

Immunization No adult vaccines taken including COVID-19 vaccine

Food & Drug Allergies No known food & drug allergies

Blood Type & Transfusion Blood Type A+. No history of blood transfusion
History
 Family History
Patient’s Father Patient’s Mother Patient’s wife
Worked at a junkshop Housewife Housewife
Died at 80 y.o. Due to old Died at 80 y.o. due to old Died at 77 y.o. due to
age age COVID-19 complications at
LPH

Heredofamilial
Patient’s Sibligs Patient’s Children
diseases
8 siblings 7 children No other known
2 died during Typhoon Yolanda 4th child died at 37 y.o. due to liver heredofamilial diseases
1 died due to DM complcations disease
4 other are alive and well All other children are alive and well
 Personal & Social History
● Educational attainment: Elementary graduate (Abuyog Academy)
● Living conditions:
○ Currently living with his son, living expenses shouldered by son
○ House is made of wood & concrete with metal roofing.
○ Does not have pets, complains of mosquito problems in the house
○ Toilet facility: flush type w/ septic tank
○ Electricity: LEYECO
○ Daily-used water: deep well
○ Drinking water: NAWASA
○ Cooking facility: firewood & sometimes gas (located outside)
○ Garbage disposal: through daily community collection
 Personal & Social History
● Eats 3x daily (prefers vegetable & tinola)
● Preferred beverage: water; occasionally drinks carbonated drinks
● Has difficulty sleeping
○ Sleep duration lasts around 30 mins
● Does not engage in any exercises, sits on bed all day
● Smoker since 15 years old (½ to 1 pack of cigarettes/day)
● Alcoholic beverage drinker since he started smoking (prefers tuba, ½ to 2L weekly)
● No illicit drug use
● Does not visit dentist
● Prefers consultations when he gets sick, does not visit folk practitioners/alternative
medicine.
Review of Systems
General (+) Weight loss, Right leg Amputated, (+) Fatigue,
weakness, (-) fever

(+) Changes in skin color (browning) on certain areas of

Skin legs, wound scabs on the legs, gangrene of toes, dryness of
skin, (-) jaundice, rashes, lumps, sores, itching, changes in
color & size of moles

Head Hair is white, normal texture, (-) headache, head injuries,

lesions, tenderness

Eyes (+) Reading glasses. (-) tenderness, changes in color,

tearing and other discharges
Review of Systems
Ears (-) Ear aches, tenderness, discharges, use of hearing aids,
tinnitus

(-) nasal stuffiness, nose bleed, discharges, redness

Nose & sinuses

Teeth are incompete. (-) bleeding gums, sore tongue,

Mouth & Throat dryness of mouth, sore throat, hoarseness

Neck (-) lumps, goiter, pain, tenderness, stiffness

Breast (-) lumps,, pain, discomfort

Review of Systems
Respiratory (+) Cough, (-) sputum, hemoptysis, difficulty breathing

(+) Hypertension. (-) scars, palpitations, chest pain

Cardiovascular

(+) loss of appetite, constipation, change in bowel habits

Gastrointestinal (defecates every 3 days) Normal stool size and color. (-)
pain defecating and immediately after, abdominal pain

Urinary (+) Nocturia, oliguria. (-) flank pain, suprapubic pain,

dysuria, yellow urine without blood, incontinence.

Genital (-) hernias, discharges, testicular pain, masses, lesions,

itching
Review of SYSTEMS
Peripheral Vascular (+) blisters near gangrenous infected toes, (-) cramps,
varicose veins, edema

Musculoskeletal (+) joint pains. (-) gouts, numbness, stiffness

Hematologic (-) pallor, easy bruising, easy bleeding

(-) heat or cold intolerance, excessive sweating, thirst or

Endocrine hunger

Neurologic (+) lightheadedness. (-) dizziness, faintings, seizures,

tremors, involuntary movements

Psychiatric (+) difficulty getting sleep. (-) history of psychiatric disorder

 Physical EXAMINATION

Gen. Survey Vital signs

● Sitting, conscious, BP: 130/60 mmHg

oriented to person, but (elevated)
not to place and time,
slightly uncooperative, Temp.: 36.9°C
slightly incoherent,
sleepy, lethargic. Pulse rate: 92 bpm
● Unable to assess weight,
height and BMI RR: 12 cpm
● Appears chronically ill,
ectomorph O2 sat: 99%
 Physical EXAMINATION
Integument
● Warm, fair, dry, senile skin
turgor.
● Changes of skin color with light
brown patches
● (+) Wound scabs in certain areas
of the legs
● (+) Black gangrenous lesion on
left foot affecting toes and
adjacent areas
● (-) rash, petechiae, ecchymoses,
cyanosis, jaundice, edema
● Nails are pink, capillary refill at 2s,
(-) clubbing
Skull
● Skull: AT/NC, (-) deformities,
depression, lumps, tenderness
● Hair & scalp: gray in color, (-)
alopecia, lesions, redness, lice,
scales, dandruff, lumps, tenderness
● Forehead: (-) protrusion,
deformities, depression of temples,
not prominent/receding, palpable
temporal artery
● Face: symmetric, (-) signs of
distress, involuntary movements,
masses, edema
 Physical EXAMINATION
● Visual acuity not tested (uncooperative patient).
Conjunctiva pinkish, Anicteric sclera. Cornea with
arcus senilis. Pupils equally round, symmetrical, 2mm
diameter, slow reaction to light & accommodation.
● EOM intact, normal conjugate gaze, good convergence. Eyes
● Eyelashes fine, black & oriented outwards.
● Eyebrows symmetrical, fine & black with streaks of
white hair. (-) scars lesions, edema, tenderness,
crusting, drooping
● Symmetrical, aligned, (-) lesions/discharges. Firm pinnae.
● Tympanic membranes & canals intact, (-) impacted
cerumen. Ears
● Good hearing acuity, able to hear whispered words on both
ears

Nasal mucosa pinkish, (-) epistaxis, lesions, septal

deviation, congestion, flaring, tenderness, discharges, Nose
polyps
 Physical EXAMINATION
● Lips: smooth, non-cyanotic, moist, no angular
deviation
● (+) Missing teeth & dental caries Mouth &
● Oral mucosa, tongue, gingiva: pinkish, (-) tongue
deviation upon protrusion, bleeding, sores, ulceration
Throat
● Uvula at midline
● (-) inflammation of tonsils

● Supple, (-) venous engorgement, visible pulsations

● Trachea at midline
● Thyroid moves symmetrically with deglutition Neck
● (-) Palpable lymph nodes, lumps
● Range of motion not elicited (uncooperative patient)

Symmetrical, (-) discoloration, dimpling, discharges,

inverted nipples, palpable lymph nodes, lumps, Breast
tenderness
 Physical EXAMINATION
Chest & Lungs
Pain & tenderness on posterior right
lower thorax with grunting.
Symmetrical thorax. (-) lesions, masses,
retractions. Symmetrical chest expansion,
unimpaired tactile fremitus, vesicular
breath sounds, (-) crackles wheezing.
Heart
Tenderness on anterior right lower thorax.
Adynamic precordium, PMI at 5th ICS LMCL,
JVP 7.5 cm from sternal angle. Heart rate
synchronous with pulse rate. (-) murmur,
pericardial rubs, bruits
Abdomen
● Flat & symmetric. Midline
umbilicus. (-) scars, visible
peristalsis, lumps, pulsations
● Normoactive bowel sounds at
5/min.
● Tympany on upper quadrant,
dullness on lower quadrant.
● Liver span 10 cm RMCL, splenic
span 7cm. Soft to touch,
nontender. (-) masses, rebound
tenderness, organomegaly
 Physical EXAMINATION

Back & Spine

Extremities
(-) abnormal deviation, bulging
(-) paravertebral tenderness
● Right leg amputated.
● Black gangrenous lesion on left
foot predominant on toes &
adjacent areas.
● Left foot cyanotic.
● Muscle atrophy on lower
extremities.
● Radial pulse brisk, popliteal &
dorsalis pedis pulses unable to
palpate.
 Neurological EXAMINATION
Mental Status Examination

● Conscious, initially awake, but became sleepy & lethargic later on in the course of
interview & PE.
● Can still respond to questions correctly & appropriately but is slightly inattentive &
slightly incoherent
● Oriented to person but not to time & place.
● Insight is good
● Dressed appropriately but with poor hygiene
● Speech & language clear but speaks slowly & softly
● Facial expression not blunted not flat
● Not irritable but slightly uncooperative
● Memory intact
● Unable to calculate serial sevens and spell WORLD backwards due to limited
educational attainment
● Normal constructional ability
 Neurological EXAMINATION
Cranial Nerves
● CN I: (-) hyposmia, dysosmia, olfactory hallucinations, nor olfactory agnosia
● CN II: Visual acuity, visual fields and ocular fundi not tested (uncooperative patient)
● CN II, III: Pupils equally round, symmetric, 2 mm constricting to 1 mm, slow reaction to direct
and consensual light reflex
● CN III, IV, VI: Intact EOM, up, down, medial and lateral. Normal convergence. (-) nystagmus,
ptosis, twitches in the eyelids.
● CN V: Normal corneal reflex, intact sensation to hot and cold, touch and pain in all three
divisions bilaterally. Motor not elicited because the patient was uncooperative.
● CN VII: No facial asymmetry noted. No alteration in sense of taste noted.
● CN VIII: Weber midline, AC ≥ BC. Hears whispered words on both ears and responds to verbal
stimuli.
● CN IX, X: Able to swallow with intact gag reflex. Soft palate rises symmetrically, normal
phonation.
● CN XI: Not elicited (uncooperative patient)
● CN XII: (-) tongue atrophy. Tongue protrusion in the midline without deviation nor asymmetry.
Neurological EXAMINATION
Other Tests

Motor and sensory functions, reflexes, cerebellar,

meningeal and ANS tests not elicited
(uncooperative patient)
 02
Diagnosis
Salient Features and
Basis for Diagnosis
Salient FEATURES
Gen Data 77 years old, male, Filipino

● Previous amputation of right leg

HPI ● Erythema, swelling, tenderness & pain of left leg prior
to onset of skin lesions
● Blister formation with associated pus on left leg that
progressed to a gangrenous lesion on the toes and
adjacent areas
● Poor foot hygiene
● Prone to falls and foot traumas

● Diagnosed with Type 2 DM in 2016 with poor

Past Medical History compliance to medications
● Known hypertensive since March 2021
Salient FEATURES
● Occasionally drinks carbonated beverages
Personal & Social Hx ● Smoker since 15 years old (½ to 1 pack cigarettes/day)
● Alcoholic beverage drinker (½ to 2L weekly)
● Sedentary lifestyle
● (+) Weight loss, fatigue weakness.
ROS ● (+) Loss of appetite, change in bowel habits, constipation
● (+) Nocturia, oliguria
● (+) Joint pains
● (+) Difficulty in getting sleep
● (-) Nausea, vomiting
● (-) Lymphadenopathy
● (-) Dyspnea
● (-) Abdominal pain
● (-) Excessive thirst, polyuria
● (-) Change in mental status, delirium
Salient FEATURES
● Sleepy, lethargic, slightly uncooperative & incoherent
PE ● Elevated BP (130/60 mmHg)
● Changes of skin color (light brown patches) on left leg
● Wound scabs on left leg
● Cyanosis on left foot
● Muscle atrophy on lower extremities
 T IC F O O T U L C E R
DIABE
Grade 4 (Wagner Classification) / Grade 1 Stage D (University of Texas System)
 o s i s ★ Male, 77 years old

g n
Dia
★ Previous amputation of right leg

f o r ★ Uncontrolled Type 2 DM with poor compliance to medications

a s is
B ★
★ Smoker since 15 y.o. (½ to 1 pack cigarettes/day)

Blister formation with associated pus on left leg, progressed to a gangrenous lesion

★ Gangrene of the toes and adjacent areas

★ Poor foot hygiene ★ Prone to falls & foot traumas ★ Wound scabs on left leg

★ Sedentary lifestyle

★ Erythema, swelling, tenderness and pain on left leg prior to onset of skin lesions

★ Muscle atrophy of lower extremities

 03
DIFFERENTIAL DIAGNOSIS
Neuropathic Ulcer

Rule In Rule Out

❏ Hx of uncontrolled DM ❖ Charcot neuroarthropathy
❏ Male
❏ Elderly
❏ Smoker
❏ Located at sites of trauma
❏ May progress necrosis or
hyperkeratotic wound tissue
Arterial (Ischemic) Ulcer

Rule In Rule Out

❏ Age > 70 ❖ Small, annular, pale, tender,
❏ Smoker circumscribed, and dessicated
❏ Diabetic
❏ Hypertensive
❏ Located on distal areas of the limbs
❏ Sedentary lifestyle
❏ May progress to necrosis and
gangrene
Venous Ulcer

Rule In Rule Out

❏ Age > 70 ❖ Located near the medial or
❏ Smoker lateral malleolus
❏ Diabetic ❖ Brawny appearance
❏ Hypertensive
❏ Erythematous and inflamed upon
onset
❏ Trauma
❏ Sedentary lifestyle
Gas Gangrene

Rule In Rule Out

❏ Age > 70 ❖ Rapidly progressive (may
❏ Diabetic develop hours to weeks)
❏ Fever
❏ Contamination of traumatic lesions
❏ Progress to necrosis and gangrene
Squamous Cell Carcinoma

Rule In Rule Out

❏ Age > 70 ❖ No hx of amputation due to
❏ Smoker malignancy
❏ Male ❖ Rare malignancy with very
❏ Hx of amputation few reported cases that occur
on the toe.
 04
DIAGNOSTICS
e
Screening & Surveillanc
Diagnostic Tests
DIAGNOSTICS Screening & Surveillance

● Screen for distal polyneuropathy at diagnosis

● Annual comprehensive foot examination
○ Calluses, discolorations and deformities
○ Foot pulses and ankle-brachial index (ABI)
○ Loss of protective sensation
DIAGNOSTICS Classification of Diabetic Foot Ulcers
Wagner Classification System

DEPTH & INVOLVEMENT

Grade 0 Pre- or post-ulcerative lesion, completely epithelialized

Grade 1 Partial/full-thickness ulcer; superficial wound

Grade 2 Penetrates the tendon or capsule

Grade 3 Deep with osteitis

Grade 4 Partial foot gangrene

Grade 5 Whole foot gangrene

DIAGNOSTICS Classification of Diabetic Foot Ulcers
Wagner Classification System
 DIAGNOSTICS Classification of Diabetic Foot Ulcers
University of Texas System
DEPTH (Grade) Presence of INFECTION/ISCHEMIA (Stage)

Grade 0 Pre- or post-ulcerative lesion, Stage A Clean Wound

completely epithelialized ● No ischemia
● No infection

Grade 1 Superficial wound Stage B Non-ischemic infected wound

● No ischemia
● With infection

Grade 2 Wound penetrates tendon or capsule Stage C Ischemic non-infected wound

● With ischemia
● No infection

Grade 3 Wound penetrates bone and joint Stage D Ischemic infected wound
● With ischemia
● With infection
DIAGNOSTICS Plain radiographs

● Assess possibility of
osteomyelitis
● Assess for deformities
● Demonstrate calcifications of
extremity vasculature
DIAGNOSTICS Plain radiographs

Neuropathic ulcer Gas gangrene Squamous cell CA

DIAGNOSTICS

Culture
- From debrided ulcer base or from
purulent discharge / wound aspiration
- Culture from wound surface is NOT
helpful
DIAGNOSTICS MRI
● Most specific modality
● Rule out infection in the
presence of an ulcer
● Evaluate the severity of
Charcot arthropathy
● Distinguish between
arthropathy and infection
● Also used for evaluating deep
space infections, infectious
tenosynovitis, myositis, and
septic arthritis
DIAGNOSTICS MRI
Neuropathic ulcer Venous ulcer
DIAGNOSTICS CT Scan

● Identify osseous changes

● May NOT be useful in
evaluating soft tissue
infection
DIAGNOSTICS CT Scan

Neuropathic ulcer
DIAGNOSTICS

Bone scan of the

foot
- Used when MRI and CT scan is
contraindicated for evaluating osteomyelitis
- High sensitivity; low specificity
DIAGNOSTICS

Indium-111 labeled WBC Scan

- Improves specificity when compared to
bone scan and radiographic findings
- Improves sensitivity in comparison to
plain radiographs
 Management
05 Pharmacologic
 Diabetic foot risk stratification

Diabetic foot risk Findings

Normal No abnormalities

Low risk Callus alone

Moderate risk Any of the following:

● deformity
● neuropathy
● non-critical limb ischemia

High risk One of the following:

● previous ulceration
● previous amputation
● on Renal Replacement Therapy
● neuropathy and non-critical limb ischemia
● neuropathy and callus and/or deformity
● non-critical limb ischemia and callus and/or deformity
 Diabetic foot risk stratification

Diabetic foot risk Findings

Active diabetic foot Any of the following:

problem ● ulceration
● infection
● critical limb ischaemia
● gangrene
● suspicion of an acute charcot arthropathy, or an unexplained hot, red,
swollen foot with or without pain
Topical ANTIBIOTICS

The following topical antibiotics may be used in diabetic foot:

❏ Bacitracin C
❏ Getronidazole
❏ Neomycin
❏ Fusidic acid
❏ Gupirocin
❏ Silver sulphadiazine
❏ Gentamicin
 Systemic ANTIBIOTICS
Infection/Condition & Suggested Treatment Comments
Likely Organism
Preferred Alternative

Mild Infections: Cephalexin 500mg PO q6h Clindamycin Duration:1-2 weeks

a.Local infection 300-450mg PO q8h
involving skin & SC OR
tissues OR
b.Erythema, less than 2 Amoxycillin/Clavulanate
cm around the ulcer 625mg PO q8h Trimethoprim /
c.No systemic signs Sulphametoxazole
5-10mg/kg PO q12h
 Systemic ANTIBIOTICS
Infection/Condition & Suggested Treatment Comments
Likely Organism
Preferred Alternative

Moderate Infections: Ampicillin/Sulbactam Ciprofloxacin 400mg Duration: usually 2-4 weeks.

a. Deep tissue 1.5-3gm IV q6-8h IV q8-12h Modify according to clinical
infection PLUS Clindamycin response.
b. Erythema more OR Ceftriaxone 1-2gm 600mg IV q8h If proven osteomyelitis: at
least 4-6 weeks. However, a
than 2 cm around q24h PLUS/MINUS
shorter duration (3 to 5
ulcer Metronidazole 500mg IV
days) is sufficient if the
c. No SIRS q8h
entire infected bone is
removed. If antibiotic-
resistant organisms are
If pseudomonas is Piperacillin/Tazobactam
likely, treat as severe
suspected 4.5mg IV q6-8h
infection
 Systemic ANTIBIOTICS
Infection/Condition & Suggested Treatment Comments
Likely Organism
Preferred Alternative

Severe Infections: Piperacillin/Tazobactam Cefepime 1-2gm IV Add Vancomycin 1gm IV

All of the above 2 or 4.5gm IV q6-8h q8h q12h, if high risk for
more SIRS MRSA

Duration of treatment: 4-6

weeks
 ANALGESICS
Mild to moderate pain

Paracetamol 500mg every 4-6h

NSAIDs (Ibuprofen) 200-400mg every 6-8h SE: heartburn, GI symptoms, allergic reaction

Tramadol 50-100mg daily in 3 divides doses SE: somnolence, constipation, dizziness, N&V

Dihydroxycodone 10-30mg q4h

Moderate to severe pain

Morphine 10-30mg every 4-6h SE: somnolence, constipation, dizziness, N&V

Adjuvants

Amitriptyline 10-150mg OD, usu. dosed at bedtime SE: dry mouth, blurred vision, constipation

Gabapentin 300-3600mg daily in 3 divided dosage SE: dizziness, somnolence, GI upset, peripheral edema
 ANTISEPTICS

● · Iodine dressing - commonly used in infected wound in the local setting.

- antiseptic effect of iodine was not inferior to other antiseptic agents and did
not impair wound healing.
 Systemic ANTIBIOTICS
INSULIN SECRETAGOGUES

Sulfonylureas (SFU)

Tolbutamide (Orinase®) 500mg tablet, BID/TID

Glimipiride (Amaryl®) 1-8mg tablet OD SE: hypoglycemia, weight gain

Glipizide (Glucotrol®) 5-10mg, OD, or in 2 divided

dosage if >15mg

Glinides

Repaglinide (Prandin®) 0.5-2mg daily, taken in 2-3 SE: hypoglycemia

divided dosage; Duration of action: 4hrs
Max dose per meal: 4mg Take within 15-30mins of meal
 Systemic ANTIBIOTICS
EUGLYCEMICS

Biguanides

Metformin (Glucophage®, Glucophage®: 500mg tablet SE: GI symptoms, metallic taste, lactic acidosis
Riomet®, Fortamet®) BID Take with meals
Fortamet®: 500mg tablet Contraindications: kidney or liver problems, heart failure
OD treatment, excessive alcohol consumption

Thiazolidinediones

Pioglitazone (Actos®) 15-30mg OD SE: anemia, edema from fluid retention, weight gain, bone
loss or fractures
Contraindications: kidney or liver problems

GLP-1 analogs

Exenatide (Byetta®) 5mcg SQ BID SE: nausea, HA, hypoglycemia

 Systemic ANTIBIOTICS
EUGLYCEMICS

DPP-4 inhibitors

Alogliptin (Nesina®) 35mg PO OD SE: runny nose, sore throat, HA, upper resp. infection,
rarely allergic reactions

SGLT2 inhibitors

Dapagliflozin (Farxiga®) 5mg tablet OD SE: oliguria, urgency, hypotension, dizziness, UTI
 Systemic ANTIBIOTICS
Insulin 0.2–0.4 U/kg per day, given In lean individuals or
in the evening or just those with severe weight loss, in individuals with
before bedtime underlying renal
or hepatic disease that precludes oral
glucose-lowering agents, or in
individuals who are hospitalized or acutely ill

In patients who fail to reach

glycemic targets.

SE: hypoglycemia, weight loss

Systemic ANTIBIOTICS
Goals of treatment based on HbA1C
● If HbA1C is <7%, control PPG first
● If HbA1C is 7-9%, control both FPG and PPG
● If HbA1C is >9%, control FPG first
Systemic ANTIBIOTICS

Individualized therapeutic goals and modalities in older adults should consider

● biologic age,
● other comorbidities and risk factors (hypertension, CV disease, etc.),
● neurocognitive and physical functional status,
● living arrangements,
● social support, and
● other medications.
 Management
05 Non- pharmacologic
 Wound Management Non-pharmacologic

done to maintain adequate

moisture and/or remove Dressing
dead tissue

Maggot is used for

debridement of wounds Maggot Debridement
with necrotic tissues

done inside a chamber Hyperbaric Oxygen

pressurized with pure oxygen Therapy
helps infected wounds heal
more easily
Surgical Intervention
Debridement
process of removing necrotic or
foreign tissue from a wound to
promote healing
Reconstruction
(e.g. skin grafts, flaps or tissue
expansion) is vital in the
management for patients with
diabetic foot.
Non-pharmacologic
Revascularization
improves the healing of
ischaemic diabetes ulcer.
Amputation
to remove non-viable tissues due to
infection and gangrene
Major amputations usually below knee is
the gold standard
Patient Education ANTICIPATORY CARE

Personal footcare should be emphasized which includes:

● checking that feet are in good order
● keeping feet clean
● providing skin care
● keeping toenails at a good length
● choosing and wearing good fitting footwear
● getting help if a problem is noticed
Metabolic Control ANTICIPATORY CARE

Individualized A1c targets and patient’s profile

Tight (6.0 - 6.5%) 6.6 - 7.0% Less tight (7.1 - 8.0%)

Newly diagnosed DM All others Comorbidities (coronary disease,

Younger age heart failure, renal failure, liver
Healthier [long life expectancy, dysfunction)
no cardiovascular disease (CV) Short life expectancy
complications] Prone to hypoglycemia
Low risk of hypoglycemia
Foot Care ANTICIPATORY CARE
❏ Perform a comprehensive foot evaluation annually to identify risk factors for ulcers &
amputations.
❏ All patients with diabetes should have their feet inspected at every visit.
❏ Mechanical loading of the feet during activities
❏ Appropriate footwear is important for all patients with diabetes. Its importance
increases with higher risk of developing DFU.
Nutrition ANTICIPATORY CARE

EATING PATTERNS & PROTEIN DIETARY FAT

MACRONUTRIENT
DISTRIBUTION ingested protein Eating foods
appears to increase containing long-chain
Food higher in fiber insulin response ω-3 fatty acids.
and lower in without increasing recommended to
glycemic load plasma glucose
prevent or treat CVD
concentrations
Nutrition ANTICIPATORY CARE

ALCOHOL SODIUM

Only drink in limit sodium

moderation and no consumption to less
more than two than 2,300 mg/day
drinks per day
Smoking Cessation ANTICIPATORY CARE
● Advise all patients not to use cigarettes, other tobacco
products or e-cigarettes.
● Include smoking cessation counseling and other forms of
treatment as a routine component of diabetes care
Psychosocial Care ANTICIPATORY CARE
· Psychosocial screening and follow-up include:
o Attitudes
o Expectations for medical mgmt. & outcomes
o Affect/mood
o Quality-of-life (QOL)
o Resources- financial, social & emotional
o Psychiatric history
Prognosis
● it is estimated that 5–15% of patients with DM will be having
diabetic foot acute infections or necrosis which often result in
amputation as one of the worst and last resort treatment.
● long-term patient survival still appears to be poor, especially among
patients with PAD, renal insufficiency, or the combination of both
● he 5-year mortality in patients with diabetes and critical limb
ischaemia is 30% and about 50% of patients with diabetic foot
infections who have foot amputations die within five years
 Complications
● Musculoskeletal complications in diabetic foot include ulcers, infections
and deformities (e.g. Charcot’s Arthropathy).
● Diabetic kidney disease
● Diabetic retinopathy
● Others:
○ Gastrointestinal
○ Genitourinary
○ Dermatologic
○ Cataracts and glaucoma
○ Periodontal disease
○ Hearing loss
○ Increased risk for infection
○ Cheiroarthropathy
 Concept Map
06