CASE PRESENTATION ON

DIABETIC FOOT ULCER

- BY
R.ROSHNI
16GTIT0016
PHARM D 5th YEAR
 A 65yrs adult male was admitted to the GM on 24.12.2019 in
GOVERNMENT HOSPITAL CHITTOOR bearing the IP no.
20191125117

 Chief complaints :
 C/O The patient had an ingrown toe nail that became infected
several weeks ago, and now the whole foot is swollen.
History of present illness:
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.
Personal history:
Alcoholic (-)
smoking(+)
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
 S1 and S2
 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.
Vitals and systemic examination

• Patient : C/C
• Afebrile
• BP : 160/100 mm of Hg
• PR: 88bpm
• CVS: S1,S2(+)
• RS: NVBS+
• CNS: deviations of angle of mouth to right
power: 3/5 in left upper limb
4/5 in left lower limb
LAB INVESTIGATIONS
 Na 136 mEq/L
 Hgb 14.1 g/dL
 K 3.6 mEq/L
 Hct 42.3%
 Cl 98 mEq/L
 Plt 390 × 103/mm3
 CO2 24 mEq/L
 WBC 17.3 × 103/mm3
 BUN 30 mg/dL
 PMNs 78%
 SCr 2.4 mg/dL
 Lymphs 17%
 Glu 323 mg/dL
 Monos 5%
 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.
 PROVISIONAL DIAGNOSIS

Diabetic foot infection with significant

cellulitis in a patient with poorly
controlled diabetes mellitus.
 Dosage regimen
Drug Dose Freq Day1 Day 2 Day 3 Day4 Day 5
name
Inj. 1g 1-0-1 + + + + +
Cefotaxim
e
Inj. 500 mg 1-1-1 + + + + +
Metrogyl.
Inj. 50 mg 1-0-1 + + + +
Ranitidine
T. 2cc 1-0-1 + + + + +
Paracetam
ol
goals of pharmacotherapy in this case?

 o Eradicate the bacteria.

 o Prevent the development of osteomyelitis and the need for amputation.
 o Preserve as much normal limb function as possible.
 o Improve control of diabetes mellitus.
 o Prevent infectious complications.
 o Avoid adverse effects of medications.
NON PHARMACOLOGICAL TREATMENT

 Appropriate wound care by experienced podiatrists (incision and drainage,

 debridement of the wound, and toenail clipping), nurses (wound care, dressing
 changes of wound, and foot care teaching), and physical therapists (whirlpool
 treatments, wound debridement, and teaching about minimal weight-bearing with
 a walker or crutches).
 o Bed rest, minimal weight-bearing, leg elevation, and control of edema.
 o Proper education about wound care and the importance of good diabetes control,
 glucometer use, adherence to the medication regimens, and foot care in this patient
 with diabetes.
PHAMACIST INTERVENTION
Treatment of moderate infection may be with oral agents or initial
parenteral therapy while severe infections should be treated with parenteral agents.
Consider coverage for MSSA, streptococci, Enterobacteriaceae, and obligate anaerobes.
Options for IV monotherapy include:
o Piperacillin/tazobactam
o Imipenem/cilastatin
o Meropenem
 Doripenem
 o Cefepime or levofloxacin could be used;
 however, additional coverage against obligate anaerobes should be considered
 with either metronidazole or clindamycin.
 Levofloxacin is also not optimal for S. aureus coverage.
 Vancomycin IV, daptomycin IV, linezolid or tedizolid oral or IV, ceftaroline IV,
 dalbavancin IV, or oritavancin IV may be used if HA-MRSA is a suspected causative
 organism. Persons who are at high risk for HA-MRSA wound infection
 Becaplermin 0.01% gel (Regranex) is FDA approved for treatment of
diabetic ulcers on the lower Limbs and feet. Becaplermin is a genetically
engineered form of platelet-derived growth factor, a naturally occurring
protein in the body that stimulates diabetic ulcer healing. It is to be used
as adjunctive therapy, in addition to infection control and wound care.
 Comorbidities have not been treated

Thank you……