ORTHOPEDICS CASEWRITEUP

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CASE WRITE-UP

YEAR 4
FACULTY OF MEDICINE
UNIVERSITI TEKNOLOGI MARA

ORTHOPEDICS POSTING
CONFIDENTIAL

NAME

: HAKIMAH KHANI BINTI SUHAIMI

MATRIC NO

: 2008409718

YEAR OF STUDY

: 4

SESSION

: 2011/2012

SUPERVISOR

: DR. YOHAN A KHIRUSMAN

UNIVERSITI TEKNOLOGI MARA/FACULTY OF MEDICINE/MBBS220/HAKIMAHKHANISUHAIMI

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DEMOGRAPHIC DETAILS
Patients Initial: Mrs. NI
MRN: 00143343
Sex: Female
Ward: Selayang Hospital, Ward 6C/Bed 4
Age: 42 years old
Religion: Islam
Race: Malay
Address: Selayang, Selangor
Occupation: Housewife
Date of Admission: 15th November 2011
Date of Clerking: 16th November 2011
Date of Discharge: 25th December 2011
History taken from: The patient
PRESENTING COMPLAINT
Mrs. NI, a 42-year-old Malay lady, with a background history of uncontrolled diabetes mellitus
was admitted to Selayang Hospital on 15 th November 2011 due to painful right foot ulcer 4 days
after undergoing wound debridement.
HISTORY OF PRESENTING ILLNESS
She was otherwise well until 3 weeks prior to admission when she noticed an ulcer at her
right foot due to shoe scuffing. Initially, the ulcer was small, about 1cm in diameter, located at the
lateral aspect of the right 5th toe, associated with localized mild pain and foul-smelling discharge,
swelling and redness of the surrounding area, difficulty in walking and a low-grade fever.
One week later, the condition did not improve; hence she went to seek for leech therapy.
The swelling was reduced, but continuous bleeding was developed after the therapy.
Immediately, she went to ED Selayang and emergency wound debridement was done, leaving a
bigger wound at the dorsal and lateral aspects of the right foot. She was then discharged home
on the same day (due to family matters) with antibiotics and told to do daily dressing at nearby
GP.
On Day 4 post-wound debridement, the GP told her that the wound was poorly healed
with presence of pus and referred her to ED Selayang. She went to the ED, where an emergency
wound re-debridement was done. She was then admitted to Ward 6C.
Upon further questioning, this was the first episode of ulcer. She denies any other
treatment for foot. However, she noticed having pins and needles of glove and stocking
distribution, dryness of the skin at the peripheries since one year ago. She denies any rest or
night pains.

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SYSTEMIC REVIEW
No headache, no syncope, no cough, no flu, no SOB, no chest pain, no palpitation, no orthopnea,
no paroxysmal nocturnal dyspnea, no reduced effort tolerance, no polyuria/oliguria/dysuria, no
polydipsia, no abnormal thirst, no abdominal pain, no vomiting, no diarrhea, no deterioration of
vision

PAST MEDICAL HISTORY

She was diagnosed to have DM for the past 13 years and is undergoing follow up at KK Sg Tua
every 3 months. Before the current admission to Selayang Hospital, she was on oral
hypoglycemic agents (glibenclamide 10mg BD and metformin 10mg BD). According to her, the
capillary blood glucose levels were poorly controlled even though she was compliant to the drugs
(she monitors her blood glucose everyday). Recently, her morning capillary blood glucose was
>20 mmols even though she claimed that she only ate biscuits the night before.
Early this year, she was diagnosed to have hypertension during one of her regular follow ups.
She was prescribed with perindopril 8mg OD and amlodipine.
There were no other hospitalizations and no known complications from the DM and hypertension.
She denies having any heart or kidney problems.
PAST SURGICAL HISTORY
Nil
DRUG HISTORY
No other drugs
ALLERGIES
No known allergies.

OBSTETRICS HX
She was pregnant 8 times. However she had 2 hx of miscarriages and 1 hx of neonatal death due
to cx of DM.
FAMILY HISTORY
Both of her parents passed away. Her mother passed away because of some cx of DM. Father
passed away due to old age. Siblings are all healthy.
SOCIAL HISTORY
She is married and blessed with 5 children. She is a housewife whereas her husband works as a
police inspector. She does not smoke nor consume alcohol / take any illicit drugs.
DIETARY HISTORY / CULTURAL HABITS

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She controls her diet. During breakfast, she usually eats 1 glass of low fat milk and half piece of
whole-grain bread and fried egg. She usually skips her lunch. For dinner, she takes a lot of green
vegetables fried with minimal oil and served with a scoop of rice. However, she does not do
regular exercise.
Upon questioning regarding foot care, she claims that she uses different footwears, denies
walking barefoot, she inspects and washes feetregularly, and does proper nail clipping. However,
she claims that her one of her recent footwears was fit.
PHYSICAL EXAMINATION
General condition
Height: 1.60 m
Weight: 100 kg
BMI: 39.1 kg/m2 (Obese Class II)
Vital signs
Temperature: 37.90C
Blood pressure: 126/60 mmHg
Pulse rate: 88 beats/min with regular rhythm, normal volume
Respiratory rate: 18 cycles/min
Impression: Low-grade fever.
Mrs NI is a Malay lady with obese body built, lying supine on the bed supported with one pillow.
She looks comfortable and not in pain, not in respiratory distress. Shes alert, conscious and
oriented to time, place and person.
She is not pale and not cyanotic. Her hydration status is adequate.

Specific examination of the wound

(Examination was done in supine position since the patient was unable to stand because the
wound was exposed for inspection)
The affected foot (right) was compared to the left.
Inspection
On inspection, both of the lower limbs were in normal attitude, the right foot looks swollen
compared to the left. Trophic changes noted nails and skin. No fungal infections
(onychomycosis) seen. No charcots deformities, no prominent metatarsal head, bunions etc
The surrounding skin was dry (cracking) and hyperpigmented. (reduced hair?)
There was a single wound located at dorsum and lateral part of the right foot, extending from the
lateral aspect of the base of 5 th toe to 3rd toe and up to the base of the ankle, size of about 5x7cm.
Depth 0.5cm. The margin was regular, the edge was sloping with presence of granulation tissue,
the base was pink and there was no discharge or slough or blood. The extensor tendon was
exposed.

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Palpation
On palpation, the surrounding skin was warm, and non-tender. Capillary refill time was <2s.
Edema on right?
DPA was unable to palpate because of the wound but was normal in the left. PTA and popliteal
were unable to appreciate

There was reduced sensation at the glove and stocking distribution of both feet (from the toes up
to the distal third of the calves)

Free ROM. Limited for right due to wound

ABSI/ABPI - normal

Other systemic examinations

All the respiratory, cardiovascular, abdominal and central nervous system examinations were
unremarkable.
CLINICAL SUMMARY
Mrs. NI, a 42-year-old Malay lady, with a background history of uncontrolled diabetes mellitus
presented with a painful ulcer at the lateral and dorsal aspect of right foot with foul-smelling
discharge 4 days after undergoing wound debridement.
On physical examination, she was mildly febrile (37.9). The wound was single, rectangular shape,
size of about 5x7cm, extending from the lateral aspect of the base of 5 th toe to 3rd toe and up to
the base of the ankle. The margin was regular, the edge was sloping with presence of granulation
tissue, the extensor tendon was exposed and the base was pink and there was no discharge or
slough or blood. Depth 0.5cm The surrounding skin was hyperpigmented. The DPA was unable
to palpate but the PTA and popliteal were weak. Free ROM. ABSI?

PROVISIONAL DIAGNOSIS
Infected ulcer at the lateral and dorsal aspects of right foot
Reasons to support:
History of fever
History of foul-smelling discharge

DIFFERENTIAL DIAGNOSIS
1. Ischemic ulcer
Pros:

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PTA and popliteal were unable to palpate

On examination, the wound was clean

Cons:
No history of rest/night pains
ABSI normal
Wound debridement was done prior to the examination (no more foul-smelling discharge)
sensation over the left lower limb.
2. Wet gangrene
Pros:
Cons: Still viable
3. NSTI
Pros:
History of uncontrolled diabetes
Cons:
NSTI extends very rapidly

3. Cellulitis
Pros:
History of uncontrolled diabetes
Cons:
Involved more than the skin surface
Cellulitis does not require surgical debridement
4. Abscess
Pros:
5. OM
Bone exposed?

GENERAL INVESTIGATIONS
Full blood count (taken on 19th November2011) (not done during admission)
Indication: To see the WBC, to anticipate the high WBC (infective process), to monitor general
condition of the patient and look at the Hb, RBC, platelet count to prepare if case shell need
another surgical operation.
WBC 25.65 (high neutrophils)
RBC 3.94 (normal)
Hb 10.3
Platelet - Normal
Impression: High total white blood cells count might indicate an acute infection from the wound
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Tissue culture
RBS, FBS, HbA1c
RBS 14.3 on admission
HbA1c not done
ESR and CRP
ESR 13.96 (done on 24th)
-It is necessary to get wcc and ESR?
not necessary,wcc is enough to check for inflammation but ESR can be used to monitor the
progression of patient condition regarding the infection
-what is ESR? How ESR was done in lab? Normal values for ESR and the unit
>20mm/hours
-then,
what
is
CR-P?different
with
ESR
Urea & Electrolytes (taken on admission)
Indication: To assess renal function of the patient.
Test
Urea
Sodium
Potassium
Creatinine

Result
3.6
141
3.5
80

Unit
mmol/L
mmol/L
mmol/L
umol/L

Normal range
1.7-8.3
120-160
3.5-6.5
44-88

Impression
Normal
Normal
Normal
Normal

Impression: No siginificant abnormality.

Tissue culture (after WD) P.aeruginosa (came back on 16th)
XRay done on admission normal no OM changes
FINAL DIAGNOSIS
Infected secondary to
MANAGEMENT
In the emergency department
1. Vital signs monitoring.
2. WD
3. Daily dressing, elevate R LL
In the ward upon admission
Special dressing demacele with saline water
Surgical or amputation
Antibiotic IV 1.5g TDSunasyn sulbactam and ampicillin
Analgesic IM tramal 50mg TDS
Sc insulin R1 18u TDS
Sc insulin NI 26u ON
ABSI
PROGRESS OF PATIENT
16th
- FBG 8.4 on sliding scale
th
18 November 2011
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Amputated of right 5th toe. Wet gangrene. Slough ++, no pus

19th Culture mixed growth.
20th November
Pus expressed when inspected
WBC 25.15
Culture ve and +ve
XR tro Om changes eg periosteal changes and lytic lesion (late)
HBa1c?
25th November 2011
Discharged
Refer to podiatry
DISCHARGE SUMMARY
Upon discharge, the patient is stable, well and comfortable. Currently she is afebrile, Day 6 after
right 5th toe amputation and repeated WD

DISCUSSION
Mrs NI is a middle-aged lady presented with a background history of uncontrolled
diabetes mellitus. She had a history of foot ulcer which was debrided and 4 days later, she
presented again to the ED due to poor healing wound. According to National Health and Morbidity
Survey 1996, foot ulceration associated with infection is one of the leading causes of
hospitalization patients with diabetes mellitus. Approximately 15% of all patients with diabetes will
develop a foot or leg ulceration at some time during the course of their disease. Several
population-based studies report an annual incidence of diabetic foot ulceration in the range of 2%
to 3% in patients with either Type 1 or Type 2 diabetes, while the prevalence varies between 4%
and 10%. Numerous risk factors for diabetic foot ulceration have been ascertained. Mrs NI
obese class II, most probably the reason why sugar is poorly controlled despite compliant to
OHAs
However, it is known that there are 3 factors which play a role in its pathogenesis

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In the peripheral neuropathy complication of DM, patient will have abnormal sensory,
motor and autonomic symptoms. Whereas in peripheral vasculopathy, it is due to the
atherosclerosis at the medium-sized arteries which include the popliteal artery, DPA, and PTA.
And also immunopathy.

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Usually, an ulcer can be differentiated whether it is neuropathic vs ischemic ulcer

Features Ischaemic foot
There is a history of intermittent claudication.

Neuropathic foot
Hx of pins and needles

Nature of On examination indications of peripheral vascular disease (skin is On examination evidence of war
foot
cool, pale or cyanosed, shiny and thin, with loss of hair, and neuropathy (hypoesthesia or c
onychodystrophy; peripheral pulses are absent or weak; the ankle sensation of light touch, pain,
brachial index is <0.9) are present. Ulcer redness at the border, vibration, absence of Achilles
pale /yellowish/black(necrotic) base, minimal granulation tissue (poor abnormal vibration perception thres
healing)
25 V, loss of sensation in re
Non-invasive vascular testing (duplex or triplex ultrasound monofilaments, atrophy of the sma
examination, segmental pressures measurement, plethysmography), feet, dry skin and distended dor
and angiography confirm
present. However, the pattern of
peripheral vascular disease.
vary considerably from patient to pa
There are no findings of peripheral neuropathy (sensitive to sensation) normal temperature or may be war
callus formation at the borders of the
Its base is red, with a healthy granu
Peripheral pulses are present and
pressure index is normal or abo
metatarsals/pressure points), bet
granulation tissue, pulse present
Pain

Painful

Painless

Foot
pulses

Absent

Palpable

Site of
ulcer

Sides of digits (peripheries)

Rest pain
Develop on the borders or the dorsal aspect
of the feet and toes or between toes.

Plantar surface
Pressure points peripheries high pla
(metatarsal heads, plantar aspect of
or over bony prominences

Complica Ulceration/Necrosis
tions
Gangrene

Charcot's joint (not evident in this pa

In this case Mrs NI presented with a history of skin dryness (autonomic symptom) and
pins and needles at the stocking distribution of both feet (peripheral sensory neuropathy) for
one year, which correspond with the physical examination. She also has peripheral

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vasculopathy as the PTA and popliteal artery were weak and this was evidenced by the ABSI
which was ___________.
Neuro-ischemic ulcers have a mixed etiology, i.e. neuropathy and ischemia, and a mixed
appearance.

Another classification which Kings / Wagners Classification of Diabetic Foot Ulcers81Grading

Stage

description

I Stage 1: Normal

Diabetic alone 0Pre-ulcer. No open lesion. May have deformities, erythematous

pressure or hyperkeratosis.

II Stage 2: High Risk

Diabetic + neuropathy or ischaemia 1Superficial ulcer. Disruption of skin without pene

subcutaneous fat layer.

III Stage 3: Ulcerated

Diabetic + ulcer but no infection2Full thickness ulcer. Penetrates through fat to tendo
capsule without deep abscess or osteomyelitis.

IV Stage 4: Cellulitic Stage

Diabetic + infection (cellulitis) 3Deep ulcer with abscess, osteomyelitis or joint

includes deep plantar space infections, abscesses, necrotizing fascitis and tendo
infections.

V Stage 5: Necrotic

Diabetic + necrotic tissue Features 4Gangrene of a geographical portion of the foo

toes, forefoot or heel.

VI
Stage
Amputation

6:

Major Major amputation5Gangrene or necrosis of large portion of the foot requiring m

amputation.

IX- XRay
I would like to order for fasting lipid profile. Prolly she requires anti cholesterolemia
I would like to do FBC on the day of admission
~
upon admission, Kings Stage 3, but after investigations, Kings Stage 5 amputation to prevent
further extension or spread of the infection

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Debridement is the removal of all non-viable tissues and slough from theulcer. It is
only after a thorough wound debridement that application of topicalwound healing
agents, dressings or wound closure procedures are carriedout 40, 86, 87, 88.
a.Surgical debridement is an important and effective procedure in themanagement of diabetic
foot ulcers 88. This involves surgical debridementand removal of all nonviable tissue /
bone until healthy bleeding soft tissue/ bone are encountered. Diabetic foot abscesses
requires immediate incisionand drainage. Osteomyelitic bones, joint infection or gangrene
digits requireresection or partial amputation 41, 89, 90, 91. Regular and repeated
debridementof necrotic tissue leads to early closure of the diabetic ulcer 88, 92.
b.Mechanical debridement includes surgical debridement, wet-to-drydressings and highpressure irrigation 17, 40, 60, 93, 94.
c.Enzymatic debridement uses topical proteolytic enzymes as adjuvant inmanaging chronic
wounds. Their efficacy is however controversial 40, 60, 93.
d. Autolytic debridement occurs naturally in healthy, moist wound environmentwith adequate
circulation 7.
Normal saline dressings
Discharged when -

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According to a London journal abt Managing Diabetic foot, the most important thing is the
prevention which mainly involves self-Care at Home. A person with diabetes should do the
following:
Foot examination: Examine your feet daily and also after any trauma, no matter how
minor, to your feet. Report any abnormalities to your physician. Use a water-based
moisturizer every day (but not between your toes) to prevent dry skin and cracking. Wear
cotton or wool socks. Avoid elastic socks and hosiery because they may impair
circulation.

Eliminate obstacles: Move or remove any items you are likely to trip over or bump your
feet on. Keep clutter on the floor picked up. Light the pathways used at night - indoors
and outdoors.

Toenail trimming: Always cut your nails with a safety clipper, never a scissors. Cut them
straight across and leave plenty of room out from the nailbed or quick. If you have
difficulty with your vision or using your hands, let your doctor do it for you or train a family
member how to do it safely.

Footwear: Wear sturdy, comfortable shoes whenever feasible to protect your feet. To
be sure your shoes fit properly, see a podiatrist (foot doctor) for fitting
recommendations or shop at shoe stores specializing in fitting people with diabetes.
Your endocrinologist (diabetes specialist) can provide you with a refferel to a
podiatrist ororthopedist who may also be an excellent resource for finding local shoe
stores. If you have flat feet, bunions, or hammertoes, you may need prescription shoes
or shoe inserts.

Exercise: Regular exercise will improve bone and joint health in your feet and legs,
improve circulation to your legs, and will also help to stabilize your blood sugar
levels. Consult your physician prior to beginning any exercise program.

Diabetes control: Following a reasonable diet, taking your medications, checking your
blood sugar regularly, exercising regularly, and maintaining good communication
with your physician are essential in keeping your diabetes under control. Consistent
long-term blood sugar control to near normal levels can greatly lower the risk of
damage to your nerves, kidneys, eyes, and blood vessels.

Medical Treatment

Antibiotics: If the doctor determines that a wound or ulcer on the patients feet or legs is
infected, or if the wound has high a risk of becoming infected, such as a cat bite,
antibiotics will be prescribed to treat the infection or the potential infection. It is very
important that the patient take the entire course of antibiotics as prescribed. Generally,
the patient should see some improvement in the wound in two to three days and may see
improvement the first day. For limb-threatening or life-threatening infections, the patient
will be admitted to the hospital and given IV antibiotics. Less serious infections may be
treated with pills as an outpatient The doctor may give a single dose of antibiotics as a
shot or IV dose prior to starting pills in the clinic or emergency department.

Referral to wound care center: Many of the larger community hospitals now have wound
care centers specializing in the treatment of diabetic lower extremity wounds and ulcers
along with other difficult-to-treat wounds. In these multidisciplinary centers, professionals
of many specialties including doctors, nurses, and therapists work with the patient and

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their doctor in developing a treatment plan for the wound or leg ulcer. Treatment plans
may include surgical debridement of the wound, improvement of circulation through
surgery or therapy, special dressings, and antibiotics. The plan may include a
combination of treatments.

Referral to podiatrist or orthopedic surgeon: If the patient has bone-related problems,

toenail problems,corn and callus hammertoes, bunions, flat feet, heel spurs, arthritis, or
have difficulty with finding shoes that fit, a physician may refer you to one of these
specialists. They create shoe inserts, prescribe shoes, remove calluses and have
expertise in surgical solutions for bone problems. They can also be an excellent resource
for how to care for the patients feet routinely.

Home health care: The patients doctor may prescribe a home health nurse or aide to
help with wound care and dressings, monitor blood sugar, and help the patient take
antibiotics and other medications properly during the healing period.

The principles of dressing a healing wound include keeping it moist, managing exudates
using appropriate dressings, and protecting the surrounding intact skin. 15 When starting
antibiotics, the most appropriate route, spectrum of activity, and duration of treatment should be
considered, according to local policy. If the patient has systemic signs of infection, intravenous
antibiotics are needed.
REFERENCES
NHMS
5. Edmonds ME and Foster AVM. Managing the diabetic foot, 2nd ed. (Blackwell, London, 2005).
National
Institute
for
Health
and
Clinical
Excellence
(www.nice.org.uk/nicemedia/pdf/CG010NICEguideline.pdf)UK guidelines on management of
foot problems in patients with diabetes
DFU 2006
Atlas of DF
NAME OF STUDENT: Hakimah
DATE:
COMMENTS:

GRADE:
NAME OF SUPERVISOR: Dr. Yohan A Khirusman

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