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Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources
Page 1 of 67
1. We suggest that you start with the learning objectives and try
to keep these in mind as you go through the module slide by
slide.
2. Print out the mark sheet.
3. As you go along, write your answers to the questions on the
mark sheet as best you can before looking at the answers.
4. Award yourself marks as detailed on the mark sheet: one
mark for each keyword (shown in the red text) in the short
answer questions and for every correct answer in the
True/False questions.
5. Repeat the module until you have achieved a mark of > 80%
(65/81)
6. Finish with the formative multiple choice questionnaire to
assess how well you have covered the materials as a whole.
7. You should research any issue that you are unsure about.
Look in your textbooks, access the on-line resources indicated
at the end of the module and discuss with your peers and
teachers.
8. Finally , enjoy your learning! We hope that this module will be
enjoyable to study and complement your learning about
diabetic foot from other sources.
Learning Outcomes
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
4.
Epidemiology 1
Title slide
How you should
study this module
2003
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources
Page 4 of 67
Europe
Africa
Europe
Africa
872 million
667 million
863 million
1107 million
621 million
295 million
646 million
541 million
48.4 million
7.1 million
65 million
19million
7.8 %
2.4 %
7.8 %
4.3 %
Population
Total
Adult
(20-79 yrs)
2025
Diabetes
No. of people
(20-79 yrs)
Prevalence
(20-79 yrs)
Source: International Diabetes Federation and The international Working Group on Diabetes
joint publication 2006.
Epidemiology 2
Title slide
How you should
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Learning outcomes
Epidemiology
Incidence
per 1000
Population
Year
Mauritius
680
Hospital-oriented
1998-2002
Tanzania
400
Hospital-oriented
2002
Croatia
6.8
Hospital-oriented
2002
UK
2.6
Regional
1998
Information
sources
Page 5 of 67
The Netherlands
3.6
Nationwide
1991-2000
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Source: International Diabetes Federation and The international Working Group on Diabetes joint
publication 2005.
Epidemiology Quiz
Title slide
1.
2.
3.
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Epidemiology 3
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources
Page 7 of 67
Pathophysiology
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
A.
B.
C.
Trauma
Neuropathy
Pathophysiology
Title slide
Neuropathy
Motor
Sensory
Autonomic
Epidemiology
Pathophysiology
Section one quiz
Muscle wasting
Foot weakness
Postural deviation
Proprioception,
Unawareness
of foot position
Assessment
Section two quiz
nociception
Management
Section three quiz
Information
sources
Page 9 of 67
Deformities, stress
and shear pressures
Trauma
Callus formation
Reduced
sweating
Dry skin
Increase foot
Blood flow
Fissures and
cracks
Ulcer
*Shunts: blood vessels that bypass capillaries and lead directly from arteries to veins
Infection
Pathophysiology
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Artherosclerosis
narrows or blocks
the arterial lumen
Foot ischaemia
Foot ulcer
Necrosis/ Gangrene
Management
Section three quiz
Information
sources
Page 10 of 67
Infection
Artheroma plaque
narrowing the arterial
lumen
Pathophysiology
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Trauma
Dont people with diabetes feel trauma before it
reaches ulceration stage? No- thats the
problem!
Acute trauma: abrasions and burns occur often due
to the absence of nociception. Poor wound
healing makes ulcerations more likely occur.
Assessment
Section two quiz
Management
Section three quiz
Information
sources
Page 11 of 67
End of Section 1
Title slide
How you should
study this module
Well done!
You have come to the end of the first section
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources
Page 12 of 67
Section 1 Quiz
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
a)
b)
c)
d
d)
Section 1 Quiz
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
a
b
c
d
Section 1 Quiz
Title slide
How you should
study this module
Learning outcomes
Epidemiology
a)
Peripheral neuropathy
b)
c)
d)
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources
Section 1 Quiz
Title slide
How you should
study this module
Question 4: Study this flow chart and list 4 factors that predispose to
diabetic foot ulceration. Write your answer in your mark sheet
Neuropathy
Learning outcomes
Epidemiology
Motor
Sensory
Autonomic
Pathophysiology
Section one quiz
Assessment
Muscle wasting
Foot weakness
Postural deviation
Proprioception,
Unawareness
of foot position
nociception
Deformities, stress
and shear pressures
Trauma
Callus formation
Reduced
sweating
Dry skin
Increase foot
Blood flow
Fissures and
cracks
Ulcer
*Shunts: blood vessels that bypass capillaries and lead directly from arteries to veins
Infection
Assessment
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources
Page 17 of 67
Assessment
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources
Page 18 of 67
Peripheral Neuropathy
History
Claw toes
Prominent metatarsal
heads and an ulcer
Assessment
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources
Page 19 of 67
Monofilament test
Assessment
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources
Page 20 of 67
Tuning fork
test
Assessment
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Assessment
Title slide
Assessment
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources
Page 23 of 67
Callus
Bunion
Hammer toes
Claw toes
Charcot foot
Nail deformities
Assessment
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Claw toes
Nail deformity
Charcot foot
deformity
Assessment
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources
Page 25 of 67
Ulcers
Pre-ulcer assessment all done! What about after an
ulcer has developed?
Several foot ulcer classifications
have been proposed although none
is universally accepted.
The simplest classification is based
on the underlying pathogenesis:
neuropathic, ischaemic or
neuroischaemic.
It is vital to carefully monitor the
progress of an ulcer once one has
developed.
The University of Texas system
shown on the next slide can be used
to predict outcome by grading
wound depth and presence of
infection and/or ischaemia.
However there is no measure of
neuropathy.
A neuropathic ulcer on
the sole of the foot
Assessment
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Ulcer
stage
I.
II.
III.
Pre / postulcerative
lesion completely
epethelialised
Superficial
lesion, not
involving tendon,
capsule or bone
Wound
penetrating to
tendon or
capsule
Wound
penetrating to
bone or joint
Pre / postulcerative
lesion with
Infection
Superficial
lesion, not
involving tendon,
capsule or bone
with Infection
Wound
penetrating to
tendon or
capsule with
Infection
Wound
penetrating to
bone or joint
with Infection
Pre / postulcerative
lesion with
ishaemia
Superficial
lesion, not
involving tendon,
capsule or bone
with ischaemia
Wound
penetrating to
tendon or
capsule with
ishaemia
Wound
penetrating to
bone or joint
with ishaemia
Pre /postulcerative
lesion with
infection and
ishaemia
Superficial
lesion, not
involving tendon,
capsule or bone
with infection
and ischaemia
Wound
penetrating to
tendon or
capsule with
infection and
ishaemia
Wound
penetrating to
bone or joint
with infection
and ishaemia
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources
Page 26 of 67
Assessment
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources
Page 27 of 67
Infected Ulcers
How do you know if the ulcer is infected then?
Assessing foot ulcers for the presence of infection is vital. All
open wounds are likely to get colonised with microorganisms,
such as Staphylococcus aureus, and not necessarily infected.
Therefore, the presence of infection needs to be defined
clinically rather than microbiologically.
Signs suggesting
infection include;
1. purulent
secretions
2. presence of friable
tissue
3. undermined edges
4. foul odour
An infected ulcer
Assessment
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources
Page 28 of 67
End of Section 2
Title slide
How you should
study this module
Learning outcomes
Well done!
You have come to the end of the second section
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources
Page 29 of 67
Section 2 Quiz
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
1) ..
2) ..
3) ..
Section 2 Quiz
Title slide
How you should
study this module
Learning outcomes
Epidemiology
a)
b)
c)
d)
e)
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources
Page 31 of 67
Section 2 Quiz
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources
Page 32 of 67
3
4
Section 2 Quiz
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources
Page 33 of 67
I.
II.
III.
IV.
V.
Section 2 Quiz
Title slide
How you should
study this module
Learning outcomes
I.
II.
III.
Pre / postulcerative
lesion completely
epethelialised
Superficial
lesion, not
involving tendon,
capsule or bone
Wound
penetrating to
tendon or
capsule
Wound
penetrating to
bone or joint
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Ulcer
stage
Superficial
lesion, not
involving tendon,
capsule or bone
with Infection
Management
Section three quiz
Information
sources
Page 34 of 67
Pre / postulcerative
lesion with
Ishaemia
Pre /postulcerative
lesion with
Infection and
Ishaemia
Wound
penetrating to
bone or joint
with Infection
Wound
penetrating to
tendon or
capsule with
Ishaemia
Superficial
lesion, not
involving tendon,
capsule or bone
with Infection
and Ischaemia
Wound
penetrating to
tendon or
capsule with
Infection and
Ishaemia
Wound
penetrating to
bone or joint
with Infection
and ishaemia
Management
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources
Page 35 of 67
General measures
Managing diabetes and its complications requires a
multidisciplinary approach because
optimum glycaemic control is key in reducing all
complications
cardiovascular risk factors such as smoking,
dyslipidaemia and hypertension should be
addressed to reduce risks of PVD, acute coronary
syndrome and chronic renal failure
education of patients on proper foot care and on the
importance of seeking medical advice early is very
important
Management
Title slide
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources
Page 36 of 67
An example of a bad
shoe type
Management
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources
Page 37 of 67
Nail cutting
Athletes foot
Management
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources
Page 38 of 67
Callus removal
Management
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources
Page 39 of 67
If PAD is evident:
address cardiovascular
risk factors
smoking
dyslipidaemia
hypertension
Management
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources
Page 40 of 67
Foot Deformities
How should we advise patients that get
deformities?
Provide patients with the following
information:
Never walk bare footed
Visit a podiatrist regularly if you have
callus
Never try to remove corns or callus by
yourself
Prevent dryness in your feet by using
creams
Be careful not to burn your feet
Shake out loose pebbles or grit before
you put on your shoes
Run a hand around the sides of the
shoes to detect rough, worn places
Repair or replace worn out shoes
Claw toes
Management
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources
Page 41 of 67
Ischaemic necrosis of a
toe and an extensive
plantar ulcer
Management
Title slide
When the neuropathic ulcer has healed, it is vital that the patient is
fitted with a cradled insole and bespoke shoes to prevent recurrence.
Management
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources
Page 43 of 67
An air cast
Management
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
A few patients develop a cast phobia and will not wear them
Management
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
Information
sources
Page 45 of 67
Wound Debridement
What can we do to treat the ulcer?
In both isacheamic and neuropathic ulcers, treatment is based on debridement of the
wound and dressing application.
Management
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
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sources
Page 46 of 67
The larvae of the green bottle fly (which feed on dead flesh) are
sometimes used to debride ulcers, especially in the ischaemic
foot. Only sterile maggots obtained from a medical maggot farm
should be used!
Maggots produce a mixture of proteolytic enzymes that breakdown
slough and necrotic tissue which they ingest as a source of
nutrients. During this process, they also ingest and kill bacteria
including antibiotic resistant strains.
As a result of their wound cleansing activity, the application of
maggots has been found to reduce wound odour, and it has also
been reported that their presence within a wound stimulates the
formation of granulation tissue.
Contra-indications to maggot therapy:
Free range maggots should not be introduced into wounds that
communicate with the body cavity or any internal organ
They should not be applied to wounds that have a tendency to
bleed easily or contain exposed large blood vessels
They should not be applied to patients with clotting disorders, or
individuals receiving anticoagulant therapy unless under
constant medical supervision in a health facility.
Management
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
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Section two quiz
Management
Section three quiz
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Page 47 of 67
Larvaetherapy Preparations
Maggots are available in 2 forms.
1. Free Range maggots
applied directly to the wound
roam freely over the surface seeking
out areas of slough or necrotic
tissue
generally left on wound for a
maximum of 3 days.
2. BioFOAM Dressing
Maggots enclosed in net pouches
containing pieces of hydrophilic
polyurethane foam
dressing is placed directly upon the
wound surface
BioFOAM Dressing can be left for up
to 5 days then the wound is
reassessed.
Management
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
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Page 48 of 67
Wound Dressings
A sterile, non-adherent dressing should cover all open diabetic foot lesions
to protect them from trauma, absorb exudate, reduce infection and promote
healing.
Dressings should be lifted every day to ensure that problems or
complications are detected quickly, especially in patients who lack
nociception.
Additional approaches include
Skin graft:
A split-skin graft may be harvested and applied to the ulcer to speeds healing of
the ulcer which if has a clean granulating wound bed
New Developments
Management
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Are there any new interesting aids for wound healing? Yes, three here;
Hyperbaric oxygen therapy: Poor tissue oxygenation with diabetic
microangiopathy reduces wound healing. Therefore hyperbaric oxygen
therapy (HBOT) would theoretically aid in faster wound healing, there is
however little evidence for this at present.
Pathophysiology
Section one quiz
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Section two quiz
Management
Section three quiz
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Page 49 of 67
Management
Title slide
Ensure the previously described physical wound management techniques are used.
The initial antibiotic regime is usually selected empirically based upon clinical
experience and local preferences; cover of +cocci is essential as they are the usual
culprits of infection as they thrive cutaneously. Antibiotics are modified on the basis
of clinical response and and wound culture / sensitivity results. Good examples
include;
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Oral antibiotics
Perenteral antibiotics
Benzylpenicillin +/-
Flucloxacillin
Ciprofloxacillin
Cephalexin
clindamycin
Flucloxacillin
Imipenem-cilastin
Ampicillin-sulbactam
Cefuroxime
Metronidazole ( for anaerobes )
Management
Section three quiz
Information
sources
Page 50 of 67
For mild infections, 7-10 day course is usually sufficient. Severe infections
may need up to 2-3 weeks of treatment.
Management
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
An infected
ulcer
draining
pus
Acute onset;
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Acute onset
Management
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Management
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Finally, the patient may progress to bespoke footwear with moulded insoles as the
rocker-bottom charcot foot with plantar bony prominence is a site of very high
pressure. Regular reduction of callus can prevent ulceration.
During the acute stage, charcot foots foot may be misdiagnosed as;
Cellulitis
Osteomyelitis
Deep vein thrombosis
Inflammatory arthropathy
Therefore a high index of suspicion is very important at this stage!
Management
Title slide
Amputation
Learning outcomes
Amputation
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
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sources
Page 54 of 67
Pain
Management
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Drugs;
Simple analgesics; e.g. aspirin, paracetamol, and mild opiates such as codeine
phosphate singly or in combination. Prescribe hypnotics for disturbed sleep.
Management
Section three quiz
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Page 55 of 67
Management
Title slide
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
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sources
Page 56 of 67
The last decade has a dramatic interest in reconstructive foot surgery for
the diabetic foot. The aim of this surgery is to reduce risk of ulceration.
A short Achilles tendon may be associated with elevated forefoot plantar
pressure and hence may benefit from Achilles tendon lengthening
surgery.
Tenotomy of toe extensors may reduce toe deformities, thus preventing
recurrent ulcerations in this group of patients.
Metatarsal osteotomy may reduce the risk of ulcer recurrences in
subjects with prominent metatarsal heads.
However, currently there is no randomise control trial evidence comparing
these surgical techniques with medical therapy.
End of Section 3
Title slide
How you should
study this module
Well done!
You have come to the end of the last section
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
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Page 57 of 67
Section 3 Quiz
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
c)
d)
e)
Section 3 Quiz
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
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Page 59 of 67
1)
2)
3)
4)
5)
.
.
.
.
.
Section 3 Quiz
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section 3 Quiz
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
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Page 61 of 67
Question 13: name three cast techniques used for offloading pressure in neuropathic diabetic foot. Write your
answer in your mark sheet
1) .
2) .
3) .
Section 3 Quiz
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
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Page 62 of 67
1)
2)
3)
4)
5)
..
..
..
..
..
Section 3 Quiz
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
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Page 63 of 67
Oral antibiotics;
1)
..
2)
..
3)
..
4)
..
Parenteral antibiotics;
1)
2)
3)
4)
Section 3 Quiz
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
a)
b)
c)
.
.
.
Section 3 Quiz
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section 3 Quiz
Title slide
How you should
study this module
Learning outcomes
Epidemiology
Pathophysiology
Section one quiz
Assessment
Section two quiz
Management
Section three quiz
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Page 66 of 67
A.
B.
C.
D.
E.
2.
3.
4.
5.
6.
7.
8.