DAY 2

Yesterday I had one short case session with Mr Azril. He chose Diabetic Foot Ulcer Case & Im the one who examined the patient.

Our session was joined by elective student from Jogja. But since they are still preclinical. So I think many things they still blur.

This is what we had discussed yesterday.

Mr Azril: This patient 37 years old with history of diabetes melitus for 5 years presented with an ulcer. Please do lower limb examination =)

General: (eventhough the Q is LL, but still we need to give the general overview of the patient. Just observe about 30seconds for overview of patient condition. )

This is 37 years old with medium body build
Alert, conscious & comfortable.
Not in pain, not in respiratory distress.

Lower Limb Examination: (make sure to expose the patient adequately)
Look
Both leg is in normal attitude
There was no deformity, no foot drop, no clawing (hyperextension of prox phalanges & flexion of interphalangeal joint) or hammer toes, no pes planus or pes cavus
No muscle wasting ( in this patient - to detect any disuse atrophy)
No scar

There was hyperpigmentation at bilateral leg up to the knee
Skin is very dry & there is some scaly lesion
There is presence of wrinkle sign (indicate previously patient had swollen leg)
There is loss of hair
The nail is brittle
Presence of callosities at the sole

There is a gross, big & deep ulcer at the sole
extending from the big toe to the "ball of 1st toe" --> Mr Azril said to use this term
Estimating about 10cm x 5cm
with regular margin which is due to incision
The ulcer is wet, there's blood & pus with granulation tissue
There is also presence of necrotic tissue
It is foul smelling
There is expose of bone
The surrounding is dry & scally

Feel:
The leg is not warm, no edema
The ulcer is slightly tender
There is no collection of discharge/pus
The bone is not tender (to check any evidence of osteomyelitis)
For Pulse
DPA were palpable bilaterally with equal volume
PTA were not palpable
CRT <2> doc did not discuss detail which I really want to know how it is done
(use 10g monofilament, test at 10 sites..but do no how many pt cudnt feel can we say it is positive)
ABSI (assessment of healing potential)

Q: What is your diagnosis??
Diabetic foot ulcer
based on: (do give reasons straightaway, do not wait for doctor to ask)
- he's DM since 5 years ago
- there is trophic changes, callosity
- site of the ulcer

What is patophysiology behind the DFU?
Triad of neuropathy, ischemic & immune

Neuropathy - sensory, motor & autonomic
what is 1st sensory to loss in DM?? Vibration

How callos is formed?? due to loss of autonomic regulation (the sweat glands), loss of perspiration, later thick, dry callus is form. Could become crack hrough dermis & become source of infection

How clawing happened??
due to imbalance between extensor & flexor of intrinsic muscle of foot
abnormal pressure on plantar expect would lead to either pes planus or pes cavus

How DM have immunosuppression??
impaired leucocyte function (but the number of leucocyte is still the same)
slow chemotaxis & phagocytosis

How you managed this patient???
Investigation
blood investigation
1) FBC - Hb, WBC (as baseline before treatment & as preparation for pt to go to OT)
p/s- eventhough WBC pt normal doesnt mean pt does not have infection of the ulcer. its just because pt is immunosuppressed
2) BUSE
3) Renal Profile (screen for other DM cx)
4) UFEME
5) HbA1c ( glycosylated Hb - to assess the Dm control for past 3months)
6) se albumin - help in healing
7) Lipid profile
8)Swab C&S of wound

Radiological
Xray of the affected toe

===== end of session =====