Navigating a Challenging Diagnosis – A Case of Diabetes in a 74-Year-Old Patient
Managing a Complex Diabetic Foot Ulcer
Over the past week, I encountered one of the most challenging patients, a 65-year-old male with T2DM. The patient, Mr. Smith, was diagnosed with a chronic DFU on the plantar region of the left foot. He had poor glycemic control, as seen by his high HbA1c of 9.2% of people with PAD, peripheral neuropathy, and peripheral arterial disease. The ulcer was circular with an approximate diameter of 3cm, and it was swollen, exudative, and had a malodor. This case had an added infection on top of poorly controlled diabetes, which, together with vascular disease, places the patient at a high risk for amputations.
Initial Assessment and Evidence-Based Actions
Comprehensive Examination
First, the patient’s history was given, and a general physical examination was performed, with special attention to the size of the ulcer, signs of systemic infection, and blood flow in the affected limb. Difficulty was also noted in palpating pedal pulses, which could be attributed to arterial insufficiency. These comprehensive assessments have been carried out according to the IWGDF guidelines while assessing the patients with DFUs.
Diagnostic Tests
During the process of evaluating the vascular status of the patient, I requested an ABI and Doppler on the patient. The ABI was 0.6, with moderate stenosis of arteries. These diagnostic tests are aligned with the American Diabetes Association standards in that they recommend vascular assessments for patients with diabetes and foot ulcers (McClary & Massey, 2020).
Infection Management
Since the signs of infection were apparent, I started the patient on empiric antibiotic therapy using oral amoxicillin-clavulanate, which is consistent with the current IDSA guidelines for mild to moderate DFU infections. According to Carro et al. (2019), this antibiotic option is based on a realization that pathogens most commonly isolated in the management of DFUs include Staphylococcus aureus and Streptococcus species.
Evidence-Based Interventions
Glycemic Control
The most significant improvement needed regarding self-care was glycemic management. I altered the insulin dose schedule for Mr. Smith and scheduled him for a dietician visit to get further instructions regarding glycemic control. According to Bin Rakhis et al. (2022), it is important to keep blood glucose levels in check to reduce the likelihood of developing complications like DFUs.
Wound Care
Regarding wound care, I applied the concept of debridement to remove dead tissues from the wound. According to a study conducted by Manna and Morrison in 2019, the bacterial load is eradicated through debridement, and hence, the healing process is enhanced. After debridement, I used a hydrocolloid dressing because it creates a moist wound environment that promotes faster healing, according to available literature.
Vascular Referral
For moderate arterial disease, I took Mr. Smith to the hospital and referred him to a vascular surgeon for revascularization. ADA and IWGDF also recommend limb revascularization for patients with severe PAD and diabetes to improve blood flow and assist with ulcer healing (Hinchliffe et al., 2020).
Outcome and Reflection
Mr. Smith had a care plan with a multidisciplinary and holistic approach since it contains knowledge from the diabetic management, wound care, and vascular system. After two weeks, there was a significant improvement that included the reduction of the ulcer size, reduced inflammation, and better glycemic control; the interim HbA1c was 8.5%.
This case taught me about the significance of implementing guidelines into practice according to the current evidence. All steps, including comprehensive evaluation, accurate diagnosing, and specific interventions, were based on considerable research data. Successful management of Mr. Smith’s challenging DFU demonstrated the crucial importance of a multi-component, evidence-based approach in managing such patients in their everyday practice.
References
Bin Rakhis, S. A., AlDuwayhis, N. M., Aleid, N., AlBarrak, A. N., & Aloraini, A. A. (2022). Glycemic Control for Type 2 Diabetes Mellitus Patients: A Systematic Review. Cureus, 14(6). https://doi.org/10.7759/cureus.26180
Carro, G. V., Carlucci, E., Priore, G., Gette, F., Llanos, M. de L. A., Dicatarina Losada, M. V., Noli, M. L., & Amato, P. S. (2019). [Infections in the diabetic foot. Choice of empirical antibiotic regimen]. Medicina, 79(3), 167–173. https://pubmed.ncbi.nlm.nih.gov/31284250/
Hinchliffe, R. J., Forsythe, R. O., Apelqvist, J., Boyko, E. J., Fitridge, R., Hong, J. P., Katsanos, K., Mills, J. L., Nikol, S., Reekers, J., Venermo, M., Zierler, R. E., & Schaper, N. C. (2020). Guidelines on diagnosis, prognosis, and management of peripheral artery disease in patients with foot ulcers and diabetes (IWGDF 2019 update). Diabetes/Metabolism Research and Reviews, 36(S1). https://doi.org/10.1002/dmrr.3276
Manna, B., & Morrison, C. A. (2019, February 16). Wound debridement. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK507882/
McClary, K. N., & Massey, P. (2020). Ankle Brachial Index (ABI). PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK544226/
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Question 
Discuss an interesting or difficult case you encountered this past week. How did you use evidence to support your actions?
You can use a similar situation but not the same or maybe use a different disease. make sure it’s plagiarism-free. Thanks much
Length: A minimum of 500 words, not including references
Citations: At least one high-level scholarly reference in APA from within the last 5 years
Navigating a Challenging Diagnosis – A Case of Diabetes in a 74-Year-Old Patient
Example answer:
This past week while in my clinical rotation, I encountered a complex case where we had to explain to an unreceptive patient that she had diabetes. She was a 74-year-old patient who had an aversion to needles and had presented in the clinic the week prior with complaints of increased thirst, occasional lightheaded episodes, numbness, and tingling in bilateral lower extremities and had not had routine lab work done in several years. Based on these symptoms and her family history of being positive for diabetes on her mother’s side, her age, and her BMI of 39, the provider ordered labs to screen for her cholesterol and A1C.
Part of using evidence to support action in the clinical setting is to ensure that you have possible differential diagnoses and screen the patient based on those. This patient had differentials of hyperlipidemia and diabetes. The lab work eliminated the hyperlipidemia differential and confirmed diabetes with an A1C of 11.4%. After the diagnostic plan was complete, a treatment plan followed. The action plan involved educating the patient pathophysiology of diabetes, how to exercise, and preventive care, about foot care, nutrition, smoking cessation, and general hygiene, among other measures.
Clinical treatment guidelines help ensure that a provider is providing up-to-date treatment for the patient based on the most up-to-date literature without the provider having to review all of the research individually (Cash et al., 2021). For this case, we utilized the CPG published by the American Diabetes Association on the standards of care in diabetes. These guidelines help us to determine the Diabetes diagnosis based on the criteria for the diagnosis of diabetes, including an A1C >6.5% on two separate occasions (ElSayed et al., 2023). Based on this guideline, the patient had a second lab draw done at this appointment to confirm the diabetes diagnosis.