VALLANGCA, Ma.

Jessa Victoria IM Clinical Rotation

YL3-MED Rotation Date: February 1, 2019

Name: M.M.
Age: 38 y/o Religion: Roman Catholic
Sex: Male Address: Malabon
Civil Status: Single Source of History: Self
Date of Birth: November 21, 1980 Reliability of Informant: 90%
Occupation: Cook Date of Admission: January 30, 2019

Chief Complaint: Non-healing wound in the 2nd right toe

History of Present Illness:

6 weeks prior to admission, patient acquired a burn wound in the plantar surface of the 2nd right
toe from hot cooking oil while he was cooking. He attempted to remove the epidermal layer of
the wound which aggravated it. Betadine and agua oxygenada were applied to the wound.
Patient reported only of pain upon infliction of the wound. There was no fever, itching, rash, or
pus noted. No consultation was done and no medications taken.

5 weeks prior to admission, the wound was persistent with a noted increase in size. Because of
this, NSS and 10cc of Zonrox were applied to the wound. Patient also noted undocumented
fever and took Paracetamol 500 mg which provided relief. There was no itching, rash, or pus
noted. No consultation was done.

3 weeks prior to admission, patient noted no improvement of the wound. This prompted consult
to the MCU clinic. X-ray of both feet and laboratory exams were done; however, results were
not interpreted and were unknown to the patient. There was no fever, itching, rash, or pus
noted. No medications were taken.

During the interim, patient noted further increase in the size of the wound now accompanied by
loss of sensation. Persistence of symptoms and advice of peers prompted patient to seek
consult to QMMC.

Past Medical History:

Patient is diagnosed with Diabetes Mellitus Type 2 since he was 14 years old. Highest glucose
level he noted was around 500 mg/dL. He is on maintenance medication of Metformin (dose
and frequency unrecalled) but is non-compliant.

(-) asthma, hypertension, allergies, hepatitis

(-) previous hospitalizations

Family History:

(+) hypertension – father

(-) other family members with same illness
(-) allergies, cancer, hyperlipidemia, pulmonary, renal, gastrointestinal, hepatic diseases

Personal and Social History:

 Patient’s educational attainment is until Grade 5 and works as a cook.

 Patient is sedentary, does not exercise, and has a food preference for sweets and
softdrinks.
 Patient claims to have a history of illicit drug use 15 years ago, particularly shabu and
marijuana, and has claimed to stop taking these drugs.
 He drinks brandy approximately 3 times a week with approximately 10 shots per
session. Patient denies smoking.
 Patient lives in an apartment with a total of 8 members in the household.

Review of Systems:

A. General: (+) weight loss, (+) weakness, (+) fever (38 C). No fatigue, decrease in
appetite
B. Skin: no rash, sores, itching, dryness, change in size or color of moles
C. Head: no headache, dizziness, head injury
D. Eyes: (+) occasional blurring of vision. No redness, pain, glasses/contact lens,
excessive tearing, or spots
VALLANGCA, Ma. Jessa Victoria IM Clinical Rotation
YL3-MED Rotation Date: February 1, 2019

E. Ears: no tinnitus, discharge, itching, decrease in hearing

F. Nose/Sinuses: No itching, nosebleed, frequent colds, nasal congestion, discharge
G. Throat: no dryness of mouth, bleeding gums, sore throat, hoarseness
H. Neck: no lumps, stiffness, goiter, pain
I. Breast: No lumps, pain, nipple discharge
J. Cardiovascular: (+) pleuritic chest pain, (+) slight dyspnea. No palpitation, dyspnea,
orthopnea, edema
K. Respiratory: (+) Cough. No sputum, hemoptysis
L. Gastrointestinal: (+) polydipsia, (+) change in bowel habits, (+) vomiting. No
abdominal pain, nausea, dysphagia, diarrhea, constipation
M. Genitourinary: (+) urinary frequency (>1L/day), (+) frothy urine, (+) polyuria, (+)
nocturia. No dysuria, hematuria
N. Peripheral Vascular: No swelling, leg cramps, varicose veins, tenderness
O. Genital: No dysmenorrhea, discharge, history of STD
P. Musculoskeletal: No pain, gout, backache, swelling, limitation of motion
Q. Nervous: No vertigo, seizure, paresthesia, numbness
R. Hematopoietic: No easy fatigability, easy bruising
S. Psychiatric: No depression, nervousness, mood swings

Physical Exam: (done on the 2nd hospital day)

General Survey: Patient is in bed, awake, alert, responds coherently, and not in
cardiorespiratory distress. Patient is heavy-built.

Vital Signs:

PR: 65 bpm RR: 18 cpm BP: 120/70 Temperature: 36.8 C

Ht: unrecalled Wt: unrecalled BMI: unrecalled

Skin: Presence of tattoos all over the body. Noted bilateral hyperpigmentation and pinkish-
white scars on the dorsal surface of both sides of the feet. 2nd right toe was noted to be
bandaged.

Head, Eyes, Ears, Nose, Throat:

Head: Normocephalic/Atraumatic (NC/AT)

Eyes: Pale conjunctivae. Anicteric sclera. Symmetric with normal extraocular

movements. Pupils symmetrically reactive to light. Red-orange reflex was diminished
in the right eye.

Ears: Normal pinna, no external abnormalities. External canals and tympanic

membranes were not inspected (use otoscope to inpsect external canals and tympanic
membranes). No aural dicharge.

Nose: Normal nares, septum midline.

Mouth: Tongue midline without ulcerations. No inflammation on tonsils. Pharynx without

exudates.

Neck: Supple, midline trachea, no thyroid palpable. Acanthosis nigricans not present.

Lymph nodes: No masses palpable.

Lungs: Symmetric with good excursion. No retractions. Resonant upon palpation. Symmetric,
clear breath sounds.

Cardiovascular: Adynamic precodrium. No heaves, lifts or thrills. Capillary refill time brisk (<1.5
seconds). Apex beat at 5th ICS LMCL. Dorsalis pedis and posterior tibial pulses were weak
in the right leg.

Breasts: [not done due to patient’s non-consent] Check for contour (masses, dimpling,
flattening); inspect nipple (check for dimpling and symmetry, note any discharge); inspect axilla
for rash, infection, pigmentation; palpate tail of the breast tissue (check for lymphadenopathy);
in supine position, examine lateral and medial portions of the breast, palpate tail of Spence,
palpate regions of breast using 3 fingers in a smooth, rotatory motion
VALLANGCA, Ma. Jessa Victoria IM Clinical Rotation
YL3-MED Rotation Date: February 1, 2019

Abdomen: Abdomen was globular and soft to touch. Stretch marks were noted. There were no
scars, pigmentations, or mass. Upon palpation, liver edge was not palpable. Bowel sounds was
7/min.

Genitalia: [not done due to patient’s non-consent] inspect external genitalia for masses or
discharge

Rectal: [not done due to patient’s non-consent] palpate for masses

Musculoskeletal: No limitation of motion. Spine straight. [Also, check for crepitus and gait].

Neurologic and Mental Status: Alert and cooperative. Thought coherent. Oriented to place and
time.

Motor: strength of 5/5 on upper extremities; no limitation in patient’s range of motion.

Sensory: There was no loss of sensation in the plantar surface of both feet.

Cranial Nerves:

Cranial Nerve I: [not done] ask patient to close both eyes, occlude one nostril and
test smell in the other nostril with non-irritating odors like cloves, coffee, soap, or
vanilla.

Cranial Nerve II: no visual field defects; Pupils symmetrically reactive to light.
Red-orange reflex was diminished in the right eye.

Cranial Nerves III, IV, VI: extraocular movements were intact.

Cranial Nerve V: no difficulty in clenching the jaw; no noted jaw deviation (not
done: testing for facial pain and temperature sensation, corneal reflex)

Cranial Nerve VII: no noted facial asymmetry

Cranial Nerve VIII: upon normal tone of conversation, there was no noted hearing
deficit (not done: Weber and Rinne test for air and bone conduction)

Cranial Nerves IX and X: no noted hoarseness or difficulty swallowing

Cranial Nerve XI: no noted shoulder drooping or fasciculation (not done: testing
for SCM strength by asking patient to turn head to each side against your hand)

Cranial Nerve XII: no noted tongue atrophy, fasciculation, or deviation

Cerebellar function [not done]: Test for RAMs, point-to-point movements.

Reflexes: [not done] check for biceps, triceps, brachioradialis, patellar, Achilles deep
tendon reflexes; also plantar reflexes or Babinski response

Interpretative Summary:

M.M., a 38 y/o male non-smoker, known alcoholic, non-hypertensive came in to the clinic with
the chief complaint of a non-healing wound in the 2nd right toe, persistent for 6 weeks and
worsening in character. Associated symptoms include undocumented fever relieved by
Paracetamol 500 mg and loss of sensation on the wounded area. There was no noted no fever,
itching, rash, or pus. With this presentation in mind, an underlying chronic disease is considered
to cause the persistence of the wound. An infectious process is also considered, particularly
osteomyelitis.

Patient has been diagnosed with Diabetes Mellitus Type 2 since he was 14 years old. This is
confirmed with symptoms of polyuria, nocturia, and polydipsia and a recorded blood glucose of
around 500 mg/dL. This presentation rules in the consideration of diabetes mellitus foot
secondary to diabetes mellitus type 2.

Pertinent findings in the history include a sedentary lifestyle and preference for sweets and
softdrinks. Patient is also non-compliant with his maintenance medication of Metformin. With
VALLANGCA, Ma. Jessa Victoria IM Clinical Rotation
YL3-MED Rotation Date: February 1, 2019

this information, we are considering these factors to aggravate his current condition and lead to
possible complications. This consideration is further strengthened by symptoms elicited from the
review of systems which revealed weight loss, blurring of vision, and frothy urine.

Pertinent finding in the physical examination include diminished red-orange reflex, bilateral
hyperpigmentation and pinkish-white scars on the dorsal surface of both sides of the feet,
bandaged wound in the 2nd right toe, and weak pulses in the dorsalis pedis and posterior tibial
arteries in the right leg, which further strengthen the consideration of a complicated Type 2
Diabetes Mellitus.

Diagnosis and Discussion:

Primary Working Impression:

Diabetes Mellitus Foot secondary to Diabetes Mellitus Type 2 with possible Diabetic
Retinopathy, Nephropathy, and Dermopathy

To consider Metabolic Syndrome

Rule out Chronic Kidney Disease, Peripheral Arterial Occlusive Disease,

Peripheral Venous Occlusion, Osteomyelitis

Secondary Diagnosis: none

Given the history of present illness, in which the wound in the 2nd right toe was persistent
and worsened over a span of 6 weeks and the patient being diagnosed with Type 2 Diabetes
Mellitus since he was 14 years old, Diabetes Mellitus foot secondary to Type 2 Diabetes Mellitus
is considered. The signs and symptoms manifested are also consistent with Type 2 DM, which
include weight loss, polyuria, nocturia, and polydipsia. This is further proven by his blood
glucose of approximately 500 mg/dL. Also, despite being prescribed with Metformin, patient is
non-compliant, has a sedentary lifestyle, and continues intake of sweets and softdrinks.

Diabetic foot ulcer has two classification systems, namely the Wagner classification
system and the University of Texas classification system. The Wagner classification is used to
assess the ulcer depth and presence of osteomyelitis and gangrene. The wound of the patient
exposes only until the dermal layer with no penetration of tissues, indicating a full thickness
ulcer which falls under Grade 1. The University of Texas classification system determines the
ulcer depth, presence of wound infection, and presence of lower extremity ischemia. This
includes a staging system for the presence of infection and ischemia. In the patient, the
superficial wound is possibly accompanied by infection (to be determined through CBC and
blood culture) and ischemia as evidenced by weak pedal pulses in the right leg. This puts the
patient’s foot ulcer under Grade 1, Stage C.
VALLANGCA, Ma. Jessa Victoria IM Clinical Rotation
YL3-MED Rotation Date: February 1, 2019

The physical examination shows possible complications arising from his current
condition. Diabetic retinopathy may be present, as evidenced by diminished red-orange reflex in
the right eye. Patient also affirms the symptom of occasional blurring of vision. In addition,
chronic kidney disease secondary to diabetic nephropathy is considered due to the patient’s
report of frothy urine which may albuminuria. The hyperpigmentation with pinkish-white scars on
the dorsal surface of both feet may indicate diabetic dermopathy.

Type 2 Diabetes Mellitus is prevalent worldwide with a total of 3,721,900 cases in adults.
Asians are more likely predisposed to acquiring this disease in terms of phenotype because of
lower BMI, greater viscera adiposity, and reduced insulin secretory capacity. Type 2 DM is also
rising rapidly due to increasing obesity, sedentary lifestyle among individuals, and aging.

Certain risk factors are seen in the patient based on the Philippine Practice Guideline for
assessment of risk factors for Type 2 DM. The patient has a history of impaired glucose
tolerance based on his reported plasma glucose, a heavy build which may indicate an obese
BMI (BMI cannot be computed because of unrecalled height), a waist circumference of 96cm,
and a sedentary lifestyle.

The plasma glucose of the patient of 500 mg/dL also fits the patient in the diagnostic
criteria for DM.
VALLANGCA, Ma. Jessa Victoria IM Clinical Rotation
YL3-MED Rotation Date: February 1, 2019

Type 2 DM is due to the insulin resistance of the body in response to the excessive
glucose circulating in the system. In the early stages of the disease, glucose may be near
normal despite insulin resistance due to the pancreatic beta cells trying to compensate by
increasing insulin output. However, the desensitization to insulin is not anymore compensated
by hyperinsulinemia then eventually, pancreatic beta cells failure ensues and are unable to
sustain a hyperinsulinemic state, leading to a decline in insulin secretion.

Diabetic retinopathy is possibly present in the patient due to occasional blurring of vision
and a diminished red-orange reflex in his right eye. Diabetic nephropathy may also be present
due to his report of frothy urine, which may indicate albuminuria. Diabetic retinopathy and
nephropathy fall under the microvascular complications of Type 2 DM, wherein several
mechanisms are thought to be involved in producing the complications, such as advanced
glycosylation end-products binding to cell surface receptors, increased glucose metabolism of
the sorbitol pathway, alteration of genes due to increase in diacylglycerol that triggers activation
of protein kinase C, and increase in fructose-6-phosphate via the hexosamine pathway which
promotes glycosylation of proteins thereby affecting gene expression.

Weak peripheral pulses may indicate peripheral arterial disease, which is a

macrovascular complication of Type 2 DM. Hyperglycemia is hypothesized to trigger vascular
inflammation and endothelial cell dysfunction which adversely affects hemostasis. The severity
is worsened with increase in blood glucose levels and uncontrolled DM. Dermopathy is also a
macrovascular complication of Type 2 DM, wherein protracted wound healing and skin
ulcerations are commonly seen.

Differential Diagnoses:

Metabolic Syndrome
Peripheral Arterial Occlusive Disease
Peripheral Vascular Occlusion Disease
Osteomyelitis

Metabolic syndrome is to be considered for the patient because of several inclusions being met
in the criteria, particularly central obesity and increased fasting plasma glucose. In order to
further rule in the disease, a lipid profile must be done for the patient to check for
hypertriglyceridemia and low levels of HDL. Patient also has several risk factors predisposing
him to having metabolic syndrome, specifically obesity, sedentary lifestyle, and diabetes
mellitus.
VALLANGCA, Ma. Jessa Victoria IM Clinical Rotation
YL3-MED Rotation Date: February 1, 2019

Peripheral arterial occlusive disease is to be ruled out in the patient of the weak pulses
of the dorsalis pedis and posterior tibial arteries in the right leg of the patient. This disease is a
macrovascular complication of DM and increases the risk for lower extremity amputation,
causing significant long-term disabilities. The ankle-brachial index of the patient must be
obtained for initial assessment. Likewise, peripheral vascular disease is to be ruled out through
ankle-brachial index and differentiated from PAOD through Doppler ultrasound.

Osteomyelitis is to be ruled out because the chronicity of the wound may result to this
disease. It is known to be a common complication of patients with DM foot. Osteomyelitis is
further considered if the diabetic foot shows an exposed bone. The plantar aspect of the foot is
also known to be the most common site of ulceration, as seen in the patient. This disease may
only be ruled out through imaging studies such as plain radiograph of his feet.

Problem List and Management Plan:

1. Diabetic foot

Diagnostics:
a. Physical Exam
- An ulceration shall be seen in the affected area (2nd right toe in the case of the
patient); hyperpigmentation of the feet may also be expected suggestive of
diabetic dermopathy
b. Complete Blood Count
- To check for infection and possibly anemia which may be causing an impeded
wound healing; it may also check for arterial insufficiency
- Increased WBCs or leukocytosis shall be seen for an infection; decrease in
hemoglobin suggests anemia and arterial insufficiency
c. Plethysmography/Pulse-Volume Recording
- This will determine abnormalities in the pedal circulation by sensing segmental
volume changes in each pulse beat
- An irregular change in segmental volume indicates an impeded pedal circulation
d. Ankle-Brachial Index
- This is used for initial assessment in determining the severity of arterial
compromise in the extremities
- An ABI of less than 0.3 indicates poor chance for healing of distal ischemic
ulcerations
e. Doppler Ultrasound
- To rule out peripheral arterial occlusive disease and peripheral venous occlusive
disease
- Loss of Doppler signal indicates an occluded artery/vein
f. Plain Radiography of the Feet
- To rule out osteomyelitis while comparing both sides of the feet
- Osteomyelitis is seen as soft tissue swelling and loss of normal fat planes; a
periosteal reaction or Codman’s triangle is observed for severe cases
g. Blood Culture
- To determine the etiologic agent causing the infection in the wound
h. Kidney Function Test
- To check if renal function is adequate since patient will be taking antibiotics for
the ulceration
- An elevated serum-creatinine indicates abnormal kidney function

Therapeutic Plan:
Pharmacologic:
a. Antibiotics (depending on the etiologic agent)
- Oral Co-amoxiclav is indicated for infections with coverage for streptococcus and
S. aureus
- Oral Clindamycin, TMP-SMX, or Linezolid is indicated if MRSA strain is causing
the infection
- IV Ampicillin-Sulbactam or Piperacillin-Sulbactam is indicated for moderate to
severe infection caused bygram-negative aerobic organisms and anaearobes

Non-Pharmacologic:
a. Wound debridement and application of moist sodium chloride dressing
VALLANGCA, Ma. Jessa Victoria IM Clinical Rotation
YL3-MED Rotation Date: February 1, 2019

b. Ostectomy
- Indicated if wound in the 2nd right toe does not improve with antibiotics and if
wound becomes ischemic.

2. Type 2 DM

Diagnostics:
a. Fasting Plasma Glucose
- For assessment of glucose control; >/= 126 mg/dL (7.0 mmol/L) indicates
diabetes mellitus
b. Oral Glucose Tolerance Test (OGTT)
- For assessment of glucose tolerance; >/= 200 mg/dL (11.1 mmol/L) indicates
diabetes mellitus
c. Random Plasma Glucose
- For assessment of glucose control in symptomatic patients; ; >/= 200 mg/dL
(11.1 mmol/L) indicates diabetes mellitus
d. HbA1c
- For assessment of glucose control; >/=6.5% indicates diabetes mellitus
e. Lipid profile
- To check for hypertriglyceridemia (>/= 200 mg/dL) and low HDL levels (<40
mg/dL) to determine if patient has metabolic syndrome

Therapeutic Plan:

Pharmacologic:

a. Metformin – first line drug for Type 2 DM; prescribed if A1c is <9%
b. SGLT2 inhibitors – adjunct to Metformin if A1c >/= 9% and if patient has risk for
cardiovascular events

Non-Pharmacologic:
a. Lifestyle modification
- Advise patient to exercise 150 min/week of moderate aerobic physical activity
with no gaps longer than 2 days; exercise should include resistance training
b. Advise modest caloric reduction and increase in physical activity
c. Advise patient to increase consumption of soluble, dietary fiber to improve glycemic
control
d. Monitor compliance to medications by advising monthly visits

3. Diabetic Retinopathy

Diagnostics:
a. Fundoscopy
- To assess for ophthalmologic complications secondary to Type 2 DM.
- Microaneurysms, dot and blot hemorrhages, flame-shaped hemorrhages, retinal
edema and hard exudates, cotton-wool spots, venous loops and venous beading,
intraretinal microvascular abnormalities, and macular edema may be observed in
proliferative diabetic retinopathy
- Microaneurysm, retinal structural changes, and retinal ischemia may be seen in
nonproliferative diabetic retinopathy

Therapeutic Plan:

Pharmacologic:
a. Ovine Hyaluronidase Therapy
- Clearance of severe vitreous hemorrhage
b. VEGF inhibitors
- Treatment of vitreous hemorrhage

Non-Pharmacologic:
a. Laser photocoagulation
- Treatment of macular edema
b. Panretinal photocoagulation
- Treatment of choice for proliferative diabetic retinopathy
VALLANGCA, Ma. Jessa Victoria IM Clinical Rotation
YL3-MED Rotation Date: February 1, 2019

c. Vitrectomy
- If retinal detachment is seen
d. Cryotherapy
- If laser photocoagulation is occluded by opaque media such as cataracts and
vitreous hemorrhage

4. Diabetic Nephropathy

Diagnostics:
a. Urinalysis
- A 24-hour urinalysis for urea, creatinine, and protein is done to assess protein
losses and estimate the GFR
- Diabetic nephropathy will show proteinuria from 150 to >300 mg/dL, glucosuria,
and occasional hyaline casts
- To determine GFR in order to rule out CKD
b. Renal Ultrasound
- Shrunken kidneys may indicate chronic kidney disease

Therapeutic Plan:

Pharmacologic:
a. DPP4-inhibitors (-gliptins), Alpha-glucosidase inhibitors, SGLT2-inhibitors, GLP-1
agonists
- Antidiabetic agents that may be used for Type 2 DM if patient has concomitant
kidney disease

Non-Pharmacologic:
a. Diet modification
- Protein restriction of 0.8-1g/kg/d is suggested for Type 2 DM patients with renal
disease
b. Optimal blood glucose control
c. Avoidance of nephrotoxic agents such as NSAIDs and aminoglycosides

Sources:
 Harrison’s Principles of Internal Medicine, 19th ed.
 Philippine Practice Guideline for Diabetes
 Thiruvoipati, T., et al. Peripheral artery disease in patients with diabetes: Epidemiology,
mechanisms, and outcomes. US NIH. doi: 10.4239/wjd.v6.i7.961
 Malhotra, R. Osteomyelitis in the diabetic foot. US NIH. doi: 10.3402/dfa.v5.24445
 Lopez-Rowe, V. Diabetic ulcers. Medscape. Retrieved from
https://emedicine.medscape.com/article/460282-treatment#d9
 Bronze, M.S. Diabetic foot infection medications. Medscape. Retrieved from
https://emedicine.medscape.com/article/237378-medication
 Bhavsar, A.R. Diabetic Retinopathy treatment and management. Medscape. Retrieved
from https://emedicine.medscape.com/article/1225122-treatment#showall
 Batuman, V. Diabetic Nephropathy. Medscape. Retrieved from
https://emedicine.medscape.com/article/238946-treatment#d15
VALLANGCA, Ma. Jessa Victoria IM Clinical Rotation
YL3-MED Rotation Date: February 1, 2019

Personal Reflection:

1) Please rank the following components for this activity from 1-5 (with 1 being the easiest,
5 hardest):
bedside history-taking and physical exam - 3
discussion of differential diagnosis - 4
generating problem list and plan - 5
organizing case presentation - 2
organizing written report - 1

2) What made your #1 activity easy? What made your #5 activity difficult?

Organizing the report was easy because the flow and format is already given.
Generating problem list and plan is challenging because it needs to be patient-specific,
therefore a lot of factors need to be considered.

3) What improvements can you make for your performance in the next activity?

It will be better if I did a better history taking next time and a more organized physical
exam with the patient.