Case Study and Soap Note – 50y/o White Female with a Wound on her Left Foot

Julia King is a 50y/o white female who presents to the office with a c/o wound to her left foot for the past few days. States she tripped and fell while barefoot, scraping the top of her foot on the pavement. She denies any other injury from the incident. Over the past 24 hours, the wound has had “smelly” drainage. Has been experiencing some numbness, tingling, and pain, but denies fever and chills. Did not seek medical attention at the time of injury. Has been using hydrogen peroxide to clean her wound. Her last tetanus shot was 15 years ago. Patient PMHx is significant for DM II. States that she takes her medications when she remembers and does not always check her blood sugar.

PMHx:

Asthma: no hospitalizations for exacerbation.

DM II

PSHx:

Denies

SHx:

Smokes 1 pack of cigarettes per day for 5 years.

ETOH: socially

Illicit drugs: denies

FHx:

Mother 71 y/o with a history of diabetes and obesity

Father 72 y/o with a history of HTN

Brother 51 alive and well

Sister 48 with a history of HTN and diabetes

No family history of colon, ovarian, or uterine cancer

No history of CAD or PVD

Medications:

Metformin: 500mg BID po – did not take the last few days

Albuterol MDI: 2 puffs every 6 hours prn – last used 3 days ago

Singulair: 10mg po daily

Allergies:

PCN: hives and facial swelling

LNMP: N/A

G2p2

ROS:

General: denies any weight changes, fatigue, or fever; + body aches

Skin: denies any rashes; + wound to left foot

HEENT: denies headache, head injury, dizziness, or lightheadedness; denies any vision changes; denies any hearing changes, tinnitus, vertigo, or earache; denies any nasal congestion, discharge, nose bleeds, or sinus tenderness; denies any sore throat, difficulty swallowing

Neck: denies any swollen glands, pain

Breasts: denies any pain, discharge

Respiratory: denies any dyspnea; positive cough and wheezing

CV: denies any chest pain, edema

GI: denies any nausea/vomiting/diarrhea/constipation; denies bloody stools

PV: denies swelling in face, and hands. No history of leg cramps or past clots in extremities. States have swelling in the left foot

GU: denies frequency, urgency, burning; denies vaginal discharge, itching, sores

MS: denies any weakness, numbness, erythema, twitching, or pain. No h/o of backaches or fx’s. No joint pain, tenderness, or history of head trauma. Positive for left foot pain

Psych: denies nervousness, depression

Neuro: denies Headache, dizziness, vertigo, syncope, weakness; + numbness to right LE

Heme: denies any easy bruising

Physical Exam:

Vital signs:

5 (tympanic), 180/100, 90, 22, O2 sat 95% on RA
Height: 5’5ʺ
Weight: 250 lb
Blood glucose: 230 (Fasting; states has not eaten yet today)

Patient awake, alert, oriented x 4 with no apparent distress (NAD)

Skin: warm, dry, color WNL. 4 cm lesion noted to anterior left foot with crusting and purulent drainage; + surrounding erythema extending up 7 cm proximally

HEENT: head nontraumatic, normocephalic

Pupils PERRLA, EOMs intact; disc margins sharp, without hemorrhages, exudates; no AV nicking noted

Ears: bilateral TM with a good cone of light and intact

Nose: mucosa pink, septum midline; no sinus tenderness appreciated

Mouth: mucosa pink, moist; tongue midline; tonsils 1+ without exudate

Neck: supple; trachea midline; without any lymphadenopathy

Resp: regular and unlabored; lungs with end-expiratory wheezing throughout

CV: RRR, S1 and S2 noted; no s3, s4 or murmur appreciated

Abdomen: soft, non-distended; BS + x 4; no tenderness with palpation; no CVA tenderness with percussion

Genitalia: deferred

Rectal: deferred

Extremities: warm and dry with edema to left foot; calves supple, non-tender

PV: No swelling noted to hands, feet or face. Positive swelling to left foot

MS: + swelling to left foot; + tenderness of 2^nd–4^th left metatarsals; + left pedal pulse; Cap refill < 2 sec.

Neuro: alert, cooperative; thought coherent; oriented x 4; cranial nerves I-XII intact

Differentials

The patient presented with a smelly, draining wound upon sustaining a fall injury. Diabetic foot ulcers are a likely diagnosis in this case. Diabetic foot ulcer is a complication of diabetes and a common presentation in patients with uncontrolled diabetes. Trauma is a trigger for diabetic ulcers. Wang et al. (2022) note that diabetic foot ulcers may develop within hours of sustaining a trauma on the extremities and are often accompanied by numbness and tingling sensations on the affected foot. The patient is a known diabetic. She is non-compliant with her medications and does not frequently visit the clinic. At the time of her presentation, she was hyperglycemic, as demonstrated by her fasting blood glucose. She also experienced a tingling sensation and numbness on the affected foot. These manifestations affirm the diabetic foot ulcer diagnosis.

Another differential is gas gangrene. Gas gangrene manifests as an infectious wound along with other systemic symptoms such as fever and chills. It may develop within hours of sustaining an injury and is caused by Clostridium spp. Patients with low immunity and local tissue hypoxia are at high risk of developing the disease. The patient in the case presented sustained an injury on her foot. She also has uncontrolled diabetes and may have been suffering from local tissue hypoxia due to poor vascular supply attributed to diabetes. However, the gas gangrene differential may not be considered in the case due to the absence of systemic symptoms.

Another likely differential is infectious wounds. Infectious abrasion puncture often proceeds to an abrasion injury. The most likely cause of the infection is contamination, especially when cleaning. The patient in the case had an abrasion wound and was cleaning it using hydrogen peroxide. While hydrogen peroxide is a disinfectant, the material used may have allowed the entry of contaminants.

Concerning Medical Diagnoses

The medical diagnosis of concern in the patient is diabetes mellitus. The patient is a known diabetic, non-compliant with her medications and clinical visitations. This diagnosis considerably impacts other diagnoses. Diabetes is a modifiable risk factor for many chronic illnesses. Uncontrolled disease results in microvascular complications, such as diabetic neuropathy, nephropathy, and retinopathy, in the long term (Tomic et al., 2022). Diabetic neuropathy, a microvascular complication of the disease, results when peripheral nerves are damaged due to sustained hyperglycemia. Diabetic foot ulcers are a common manifestation of diabetic neuropathy. These ulcers are a consequence of sensory loss and poor vascular supply accompanying the disease. Other common medical diagnoses impacted by diabetes include diabetic blindness, chronic kidney disease, stroke, and others. This highlights why diabetes mellitus diagnosis should be given priority when managing this patient.

Diagnostic Imaging

The common diagnostic imaging applicable in making a definitive diagnosis for patients presenting with diabetic foot ulcers includes plain X-rays, magnetic resonance imaging (MRI), and arterial Doppler index (Ibrahim et al., 2022). Plain X-rays help assess bone involvement. They can reveal the presence of an underlying osteomyelitis. MRI helps reveal the extent of the Charcot arthropathy and can be used to distinguish an infected foot ulcer from a Charcot arthropathy. They are thus used where infection is likely. Arterial Doppler with ankle brachial index can be used to rule out any peripheral vascular disease that may be contributing to the current presentation, such as atherosclerosis.

Labwork

Labwork that may be necessary in this case includes HbA1c levels, complete blood count, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) (Ibrahim et al., 2022). HbA1c levels will indicate the average glycemic levels and may reveal the extent of the disease. CBC may reveal the presence of an infection. Leukocytosis upon CBC is indicative of an infected wound. CRP and ESR can predict the presence of peripheral vascular disease and osteomyelitis that may also be contributing to the presenting manifestation. In the patient’s case above, CBC and HbA1c levels are anticipated to be abnormal. The presence of smell and drainage on the patient’s wound may be indicative of an infection and can be confirmed by leukocytosis upon CBC. The HbA1c levels are also expected to be elevated since the patient has been non-compliant with her medications.

Comprehensive Care Plan

A comprehensive care plan for the patient in the case presented includes wound management, diabetes management, and patient education on foot care. In this respect, upon determining the levels of HbA1c levels, the patient will be started on diabetic pharmacotherapy using oral hypoglycemic agents. This intervention is aimed at ensuring optimal glycemic control. Bin Rakhis et al. (2022) note that optimizing glycemic control minimizes diabetic complications and offers a better guarantee of wound healing for ongoing diabetic ulcers. Wound management is another priority intervention in this case. In the presence of an infection, the patient will be started on parenteral antibiotics. The choice of antibiotics will be dependent on the implicated organism. Another point of care during wound management is to clean the wound. Patients should be educated on optimal wound care. She should be told to avoid walking barefoot due to the risk of injury, bathe her feet in lukewarm water, always keep her feet dry, and report to the clinic in case she sustains an injury on her feet.

References

Bin Rakhis, S., AlDuwayhis, N. M., Aleid, N., AlBarrak, A. N., & Aloraini, A. A. (2022). Glycemic control for type 2 diabetes mellitus patients: A systematic review. Cureus. https://doi.org/10.7759/cureus.26180

Ibrahim, A., Berkache, M., Morency-Potvin, P., Juneau, D., Koenig, M., Bourduas, K., & Freire, V. (2022). Diabetic foot infections: How to investigate more efficiently? A retrospective study in a Quaternary University Center. Insights into Imaging, 13(1). https://doi.org/10.1186/s13244-022-01228-1

Tomic, D., Shaw, J. E., & Magliano, D. J. (2022). The burden and risks of emerging complications of diabetes mellitus. Nature Reviews Endocrinology, 18(9), 525–539. https://doi.org/10.1038/s41574-022-00690-7

Wang, X., Yuan, C.-X., Xu, B., & Yu, Z. (2022). Diabetic foot ulcers: Classification, risk factors, and management. World Journal of Diabetes, 13(12), 1049–1065. https://doi.org/10.4239/wjd.v13.i12.1049

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Question

Case Study and Soap Note

Review the information provided and answer the questions. Be sure to cite your references. Look at the case study as if the subject is a patient in your office seeking care. What are your immediate concerns? What needs to be done for them? Be thorough and succinct in your responses. Your submission must be in SOAP note format.

Case Study/SOAP Note:

PMHx: