DIABETIC FOOT ULCER

History

58 year old Malay male

Underlying

-        -  DMT2( on insulin 24/24/24/20 unit,

-        -   HPT on T Amlodipine 10mg OD

-          Complain of right 3rd toe pain for the past 1/52 Pain score 5/10, throbbing in nature, gradual in onset, progressively worsen. Non radiating. Worsen upon movement, reduce by rest.

-           Associated with swelling, initially started at right third toe, increase up to dorsal right foot with redness surrounding and warm upon touch.

-          3/7 ago noted foul smelly pus discharge. Upon further history, pt claimed step on glass piece 1/52 prior to the symptom. No history of insect bite.

-           Pt done cataract removal 2 years ago on left eye and told by the doctor to have early stage kidney disease (he denied skin itchiness (hyperuraemia). He denied hx of stroke and heart diasese, however had numbness over the hand and foot occasionally.

-          Lately patient also had polyuria/ polydipsia. BSP monitoring at KK range from 7-15. Unsure about HBA1C.

-     

      Physical Examination -  Systemic +Local

-   Management

1.       Non operative

• Pharmaco

» Antibiotic - Cover polymicrobial - broad spectrum antibiotic

» Analgesic » OHA or insulin

• Non Pharmaco

 » Close monitoring sugar - refer medical for proper glucose control

 » Refer dietician for diabetic foot and high protein diet ( incase albumin low)

» Total Cast - reduce foot pressure

» Off load shoes

» Foot care - hygine, check with mirror, cut nail properly

» Refer occupational therapist - Customade shoes

2.       Surgical

• Wound Debridement - Remove slough and necrotic tissue, add drain if +pus/abcess

• Rays Amputation

• Below Knee Amputation

• Above Knee Amputation

• Ankle Brachial Systemic Index Systolic BP ankle divide with SBP Brachial Artery

• Normal ABSI value?

0.9 - 1.2 

Less : Peripheral Vascular Disease 

More : Atherosclerotic vessel

• Wegner classification DFU (Grade)

 0 High Risk Foot, no ulcer

 1 Superficial

2 Deep ulcer involved ligament/ms not bone no abcess

3 Deep Ulcer + Osteomyelitis/ abcess

4 Localized Gangrene

5 Extensive gangrene involve whole foot

• Pathophysiology DFU 

» Immunopathy » Vasculopathy » Neuropathy

• HBA 1C 

» Glycated Haemoglobin - average glucose control for the past 3 month

 » In T2DM target  <6.5%

• Diagnostic T2DM

» Venous blood sugar : Fasting 7 or more

» Random 11.1 or more

» HBA1C : 6.3 % or more

• Factor reduce wound healing

» Anaemia

» Infection

» Hypoalbuminaemia

» Uncontrolled Glucose

» Unability to offload the affected area

» Poor Circulation

• What to look in investigation?

» FBC - anemia? Leucocytosis

» ESR- trend increasing or decreasing after give

antibiotic chronic inflammation

» CRP - acute infection

» RFT – hypoalbuminemia

• What is Hyperdermatosclerosis

» Chronic venous insuficiency - inflammation

subcutaneous tissue

• Antibiotic

» IV Unasyn

» If staph Aureus - Gram Positive – Cloxacillin