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VALLANGCA, Ma. Jessa Victoria

YL3-MED

Name: M.M. Age: 38 y/o Sex: Male Civil Status: Single Date of Birth: November 21, 1980 Occupation: Cook

IM Clinical Rotation Rotation Date: February 1, 2019

Religion: Roman Catholic Address: Malabon Source of History: Self Reliability of Informant: 90% Date of Admission: January 30, 2019

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

History of Present Illness:

6 weeks prior to admission, patient acquired a burn wound in the plantar surface of the 2 nd 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

VALLANGCA, Ma. Jessa Victoria

YL3-MED

IM Clinical Rotation 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 2 nd 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. 2 nd 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 5 th 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

YL3-MED

IM Clinical Rotation 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 2 nd 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

YL3-MED

IM Clinical Rotation 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 2 nd 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 2 nd 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.

ischemia as evidenced by weak pedal pulses in the right leg. This puts the patient’s foot

VALLANGCA, Ma. Jessa Victoria

YL3-MED

IM Clinical Rotation Rotation Date: February 1, 2019

YL3-MED IM Clinical Rotation Rotation Date: February 1, 2019 The physical examination shows possible complications

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.

a waist circumference of 96cm, and a sedentary lifestyle. The plasma glucose of the patient of

The plasma glucose of the patient of 500 mg/dL also fits the patient in the diagnostic criteria for DM.

VALLANGCA, Ma. Jessa Victoria

YL3-MED

IM Clinical Rotation Rotation Date: February 1, 2019

YL3-MED IM Clinical Rotation Rotation Date: February 1, 2019 Type 2 DM is due to the

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.

factors predisposing him to having metabolic syndrome, specifically obesity, sedentary lifestyle, and diabetes mellitus.

VALLANGCA, Ma. Jessa Victoria

YL3-MED

IM Clinical Rotation 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 (2 nd 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 2 nd 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, 19 th 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

Bronze, M.S. Diabetic foot infection medications. Medscape. Retrieved from

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

VALLANGCA, Ma. Jessa Victoria

YL3-MED

Personal Reflection:

IM Clinical Rotation Rotation Date: February 1, 2019

1)

2)

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

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.