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A 43-year old male complained of having a painful left foot with foul-smelling purulent discharge from a non-healing ulcer on the sole for two months despite trying various over-the-counter medications. He had injured his foot while gardening. He also reported feeling easy fatiguability.

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1. 43-year old male

2. painful left foot with foul-smelling purulent discharge from a non-healing ulcer on the sole

3. for two months

4. despite trying various over-the-counter medications

5. injured his foot while gardening

6. reported feeling easy fatiguability

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On further questioning, the patient complained of excessive thirst,  frequent and voluminous urination, especially at night.

He did not report painful urination or any discolouration of the  urine, feeling feverish or any loin pain.

Past medical history

There was no history of similar illness in the past. The patient had  never been hospitalised.

Allergies and medications

The patient had no allergies and was not on regular medications.

Family history

There is no family history of similar illness.

Social history

There was no history of smoking, alcohol consumption or drug  abuse.

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1. 43-year old male - mid age adult. most cause: type 2 diabetes, coronary heart dx, lung cancer , MSK disorder.

2. painful left foot with foul-smelling purulent discharge from a non-healing ulcer on the sole - impaired wound healing due to underlying cause , have infxn due to prolonged inflammation

3. for two months - 4 to 6 weeks normal wound healing. Chronic condition due to infxn.

4. despite trying various over-the-counter medications : - not treating underlying medical condition ( lack of blood supply to lower extremities)

5. injured his foot while gardening - stepped on sharp object leads to purulent disharge.

6. reported feeling easy fatiguability - lack of energy performing task. causes : hyperglycemia, systemic infxn , constain pain, chronic inflammation leads to anaemia.

Diff. diagnosis:

1. Infection (bacteria)

2. Diabetis

3. peripheral vascular disease (non-healing ulcer)

4. CVS disease - venous insufficiency

5. immunocompromised (HIV)

Further inv:

1. HOPI

sites : exact location felt hurt sole or any other region

onset:

characteristic: color of pus , yellow: mild brown: chronic

radiation: radiate to any other organ

a/w sx : fever, headache , high BP - systemic review (sx of diabetes - polyuria, polydipsia (INCREASE IN THIRST) ,increased hunger, weight loss

Time: changes during two months

exarcerbating & relieving factor: what trigger/ relieve pain

Severity : using scale 1 to 10

2. pmh : med condition, past surgeries , hospitalization & procedures

3. fam history : any fam members have similar sx (diabetes is can be hereditary factor)

4. social history : alcohol, smoke intake , drug abuse, dietary

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1. Loin pain - localised pain in region of either side of spine

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1. excessive thirst

2. frequent and voluminous urination, especially at night

3. did not report painful urination or any discolouration of the  urine

4. There was no history of similar illness in the past. The patient had  never hospitalised

5. no allergies and was not on regular medications.

6. no family history of similar illness.

7. no history of smoking, alcohol consumption or drug  abuse.

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The patient was examined by the general practitioner.

Vital signs

The patient's values: Normal range

Temperature 37.2 ºC: 36.6 – 37.2ºC

Heart rate 100 beats per minute :60 – 100 beats per minute

regular sinus rhythm

Respiratory  rate 16 breaths per minute: 12 – 16 breaths per minute

Blood  Pressure 150/100 mmHg: 120/80 mmHg

BMI 33 kg/m2 (normal range: 18.5 – 24.9 kg/m²)

On physical examination,the patient was alert and oriented.

Left foot: suppurative ulcer with adjacent cellulitis extending to the  ankle joint. The foot was warm with palpable peripheral pulses.

Peripheral nerve examination: Achilles tendon reflex and vibration sensation were absent on the left foot.

Review of other systems: unremarkable.

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1. excessive thirst- due hyperglycemia, osmotic effect

2. frequent and voluminous urination, especially at night- due diabetes mellitus (osmotic diuresis), diabetes insipidus, renal disease. Nocturia- due diabetus mellitus/insipidus, hypertension, drinking habit.

3. did not report painful urination or any discolouration of the  urine- might be diabetes mellitus, no UTI as one of chronic complication of diabetes mellitus (diabetes nephropathy)

4. There was no history of similar illness in the past. The patient had  never hospitalised- have hyperglycemia symptom, type 1 rapid develop, type 2 slowly develop

5. no allergies and was not on regular medications- no allergic and medication causes

6. no family history of similar illness- rule out hereditary factor, diabetes can be acquired (cannot rule out)

7. no history of smoking, alcohol consumption or drug  abuse- rule out common risk factor (vascular problem), rule immunocompromised disease

DIFFERENTIAL DIAGNOSIS

1. Infection (bacteria)

2. Diabetis mellitus

3. peripheral vascular disease (non-healing ulcer)

4. CVS disease - venous insufficiency

5. immunocompromised (HIV)

FURTHER INVESTIGATION

1. vital sign - temp, HR high,RR,BP high(check for orthostatic hypotension)

2. BMI - high BMI, high risk DM type 2 and venous insufficiency

3. PE- INSPECTION ( peripheral cyanosis, pallor, gangrene, scar, calluses). PALPATION (temp at leg, if cold indiacte low perfusion, check pulse if low indicate peripheral vascular disease). SENSATION (monofilament test to check nerve condition)

4. Neurological examination- CN examination, motor reflex, sensory, coordination balance, eye examination (tgk cataract, observe acetone on breath due high KB)

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Achilles tendon reflex - ankle jerk reflex ,evaluate fx of nerve

Cellulitis - bacteria skin infection that cause swelling, redness,warm at the affected area of skin

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Vital signs

The patient's values: Normal range

Temperature 37.2 ºC: 36.6 – 37.2ºC

Heart rate 100 beats per minute :60 – 100 beats per minute

regular sinus rhythm

Respiratory  rate 16 breaths per minute: 12 – 16 breaths per minute

Blood  Pressure 150/100 mmHg: 120/80 mmHg

BMI - 33kg/m2

patient was alert and oriented

suppurative ulcer with adjacent cellulitis extending to the  ankle joint

foot was warm with palpable peripheral pulses

Achilles tendon reflex and vibration sensation were absent on the left foot

Other systems unremarkable

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Laboratory investigations:

LFT: within a reference range.

RFT: within a reference range.

Foot ulcer swab culture and sensitivity: Bacteroides fragilis sensitive to metronidazole, carbapenems, chloramphenicol, and  combinations of a penicillin and beta-lactamase inhibitors.

The patient was diagnosed to have type 2 Diabetes mellitus  complicated with a foot ulcer and started on metformin treatment. The  patient showed improvement, blood sugar levels decreased. His foot  was treated with a daily dressing in addition to an oral antibiotic  prescription.

The patient was counselled to optimise his weight and stick to a healthy  lifestyle, including adjustment of the diet. A goal was set on how much  weight he should lose by the next follow- up.

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Vital signs

The patient's values: Normal range

Temperature 37.2 ºC - slightly high , compensatorymechanism dt infection

Heart rate 100 beats per minute - psychological n inflammatory respons / obese , atherosclerosis

Respiratory  rate 16 breaths per minute - pyschological response

Blood  Pressure 150/100 mmHg ; obese , atherosclerosis, arteriolosclerosis (complications)

BMI - 33kg/m2 ; obesity - lead to type 2 DM, insulin resistance - impaired glucose uptake, have sx of polyuria

patient was alert and oriented - not in respiratory distress condition

suppurative ulcer with adjacent cellulitis extending to the  ankle joint - pus formation due to infection, DM type 1 & 2

foot was warm with palpable peripheral pulses - rule out PVD // cardinal signs of inflammation

Achilles tendon reflex and vibration sensation were absent on the left foot - NO diabetic neuropathy - NO nerve damage

Other systems unremarkable

DIFFERENTIAL DIAGNOSIS

1. Diabetis mellitus

2. Infection (bacteria)

3. peripheral vascular disease (non-healing ulcer)

4. CVS disease - venous insufficiency

5. immunocompromised (HIV)

FURTHER INVESTIGATION

FBC - blood test

Serum electrolytes - Hydration status

Random BG test

Blood C&S - sample from blood / pus

Urinalysis - detect presence of glucose

HbA1c - detect risk of complication

Ultrasound - to confirm venous insufficiency

Magnetic resonance - Vein image ; any obstruction

Fasting BG test - DM >7

OGTT - Fasting blood sample | DM >11.1

LFT

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1. Describe glucose homeostasis.

2. Describe the regulation of insulin release, action and insulin signalling  pathways.

3. Correlate the defect in the action of insulin with clinical manifestation of  diabetes mellitus (DM).

4. Describe the classification of DM, explain the causes and mechanism of type 2  DM.

5. Outline the relationships between the clinical manifestations of type 2 DM and  their underlying mechanisms.

6. Describe complications of DM.

7. Describe the relationship between type 2 DM and foot ulcer. 8. Describe the scientific rationale for the laboratory tests in diagnosing DM and  its monitoring and the interpretation of the results of the tests.

9. Outline the principles of management of DM.

10. Describe the pharmacological basis of medications used in the treatment of  DM.

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-Laboratory investigations:

-Hb:low: type 2 cause anemia (easy fatigue), cause chronic kidney disease decrease EPO, poor nutrition,

-TWBC: high active infection (purulent)

-neutrophil: high -bacteria -pus (MAIN)

-monocyte: high- infection

-OTHER MARKERS: EG: compliment protein (for chronic infection indication)

-random glucose: high- -ve chronic diabetes (>15)

-normal electrolyte of kidney fx

-urinalysis: has glucose - cannot reabsorb into blood (DM)

-NO nitrate: no UTI

-no LEUKOCYTE: no inflammation

-Hba1c: specific for DMT2

-Foot ulcer swab culture and sensitivity: Bacteroides fragilis: gram -ve, anaerobic, normal in colon, normal microbiota

-sensitive to metronidazole, carbapenems, chloramphenicol, and  combinations of a penicillin and beta-lactamase inhibitors: diff. mechanism so broad spectrum, this bacteria is sensitive to all of these antibiotics (use blood C&S) to prevent bacterial resistance

-The patient was diagnosed to have type 2 Diabetes mellitus  complicated with a foot ulcer and started on metformin treatment: DMT2 d/t insulin resistance > not bind to receptors > glucose cannot pass to the cell membrane > glucose remain in blood

-metformin: anti hyperglycemic drug > control blood glucose

-The  patient showed improvement, blood sugar levels decreased: pt follow treatment regiment

- His foot  was treated with a daily dressing in addition to an oral antibiotic  prescription: prevent infection, prevent complication like osteomyelitis, promote wound healing

-The patient was counselled to optimise his weight and stick to a healthy  lifestyle, including adjustment of the diet: obese > DM, dyslipidemia, heart disease > to prevent those complications

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LO 4: compare & contrast DMT2 & venous insufficiency

NASIB SAPE YG DAPAT