CASE BASED DISCUSSION

DIABETIC FOOT WITH

MRSA INFECTION
SUPERVISOR : DR. NANI ZAITUN SPPD

By Loudry Amsal Elfa G

Internal Medicine Recidency Program – Ia
Ulin General Hospital / Faculty of Medicine, Lambung Mangkurat
University
 PATIENT IDENTITY
 Name : Mr. A
 Age : 48 y.o
 Sex : Male
 R.M.K : 1-42-22-89
 Address : Pahlawan st. No 92, banjarmasin south kalimantan
 Religion : Muslim
 Nationallity : Indonesia/Banjar
 Marriage : Married
 Date of hospitalisation : 14/3/2019
 SUMMARY OF DATABASE
 Chief complaint : wounds of the legs
 History of Present Illness
 Patient came to Ulin General Hospital suffered about wounds of the legs since 5 days before admission, at first
the wound jus like small boils, then its getting bigger (about 3-4cm) next day. The wounds feels pain
approximately in left toe so the patient cannot walk. There are no history about fever said the patient.
 Patient said first it was redish and swolen. Then approximately in left ankle the swolen area burst and expels
pus. the pus was yellowish and had foul odur. The wound getting bigger and bigger so she came to ulin. In the
right ankle the wounds not getting bigger and swolen like the left side of the patient.
 Before the wounds appears, patient said that there is no decrease of sensory of the legs, but the patient usually
walk without footwear slippers for a long time.
 Patient also complained nausea (+) sometimes, but without vomiting (-). He also easily felt full after eat since a
long time, but he more felt in the last 3 days. Epigastrical pain (+), but pain doesn’t associate with food. There
is decrease of appetite felt by the patient.
 Patient also complained about his weight loss for about 10-15 kg in 6 months.
 Urination (+), pain while passing urine (-), cough (-), shortness of breath (-), defecation (+) normal as usual
 SUMMARY OF DATABASE
PAST MEDICAL HISTORY & MEDICATION:
 The patient had a diabetes melitus since 10 years before admission, and the patient seldom to check up his blood glucose level, not
controlled routinely to the doctor. The last time (about 2-3 months) he control about his diseasse to the doctor, he get insulin 10 IU once
daily before sleep, but not injected everyday.
 The patient said that the last time he control his disease to a doctor, the doctor said that the he had a decreasing of renal function, so he
given advice to limitation his drink for just 1 glass each day
 The patient had a stroke history about 6 years ago, bu there was no hemiparese just difficult to talk. There are no Head CT Scan performed.
 The patient had a history about high level of uric acid and pain in the left toe and he usually use herbal medicine fo his paint for 2 years ago
 The patient had a history about hypertension since 10 years ago. Not conrolled routinely, he consumed amlodipin and candesartan before
but he took it if there was a symptom like a headache on him
FAMILY HISTORY :
 None of his family have a hypertension and he dont know about his parents have a diabetes melitus
 No family that have same complain with him.

SOCIAL HISTORY :
 The Patient have married for 20 years, and have one children
 He is a farmer before he get sick.
 PHYSICAL EXAMINATION
General appearance looked moderately ill Sat O2 98% on nasal 02 3 lpm
overweight VAS : 4
GCS 456
BP 130/90 mmHg PR 98 bpm regular strong RR 20 tpm Tax 36.7 oC
Head Conjuctiva Anemic (-), Sclera Icteric (-), Pupil isocore 3mm/3mm, light
reflect +/+
Neck Lymphadenopathy (-) JVP R+2 cmH20
Chest Symmetrical, retraction (-)
Lung Sonor | Sonor Vesicular | Vesicular Rhonkhi : - | Wheezing :
- -|-
Sonor | Sonor Vesicular | Vesicular
-|- -|-
Sonor | Sonor Vesicular | Vesicular
-|- - |-
Cardio Ictus invisible, palpable at MCL (S) ICS IV
LHM ~ ictus, RHM ~ SL (D) S1 S2 single, regular,
murmur (-) gallop (-)
Abdomen Flat, soefl, Bowel Sound (+) N, shifting dullness (-), epigastric
pain (+)
Liver/ unpalpable, liver span 8 cm, epigastrium tenderness (+)
 LABORATORY FINDINGS
(14-03-2019)
LAB VALUE NORMAL LAB VALUE NORMAL
Leucocyte 23.700 4.700 – 11.300 /µL Ureum 188 20-40 mg/dL
Haemoglobine 13.2 11,4 - 15,1 g/dl Creatinine 3.95 <1,2 mg/dL
Hematocrite 41.3 38 - 42%
Thrombocyte 262.000 142.000 – Natrium 131 136-145
424.000 /µL mmol/L
Albumin 2,6 3,5-5,2 g/dl Kalium 5.2 3,5-5,0 mmol/L
RBS 236 <200 mg/dl Chlorida 97 98-106 mmol/L
eGFR 19

SGOT 23 0-40 U/L

SGPT 44 0-41 U/L
 LABORATORY FINDINGS
(14-03-2019)
LAB VALUE NORMAL LAB VALUE NORMAL
URINALISA SEDIMEN
URIN
Warna Kuning Kuning Leukosit 1-2 0-3
Kejernihan Jernih Jernih Eritrosit 1-2 0-2

Berat Jenis 1.015 1.005-1.030 Epithel 1+ 1+

pH 6.0 5.0-6.5 Kristal Negatif Negatif
Keton Negatif Negatif Silinder Negatif Negatif

Protein- 2+ Negatif Bakteri Negatif Negatif

Albumin
Glukosa 1+ Negatif Lain-lain Negatif Negatif
Billirubin Negatif Negatif
Darah Samar Negatif Negatif
Nitrit Negatif Negatif
Urobillinogen Normal 0.1-1.0
Leukosit Negatif Negatif
LABORATORY
FINDINGS
LABORATORY FINDINGS
(18-03-2019)
(16-03-2019 / 08.16)

LAB VALUE LAB VALUE

FBS 40 g/dl FBS 80 g/dl

HBA1C 9.1 Ureum 92 mg/dl

Total 142 Creatinine 2.50 mg/dl

Cholesterol
HDL 29

LDL 95

Trigliserida 101

Uric Acid 10.7

 LABORATORY FINDINGS
(21-03-2019)
LAB VALUE NORMAL LAB VALUE NORMAL
Leucocyte 14.000 4.700 – 11.300 /µL
Haemoglobine 12.6 11,4 - 15,1 g/dl
Hematocrite 40.3 38 - 42%
Thrombocyte 494.000 142.000 – Natrium 133 136-145
424.000 /µL mmol/L
MCV 87.9 75-96 fl Kalium 5.6 3,5-5,0 mmol/L
MCH 26.8 28-32 fl Chlorida 106 98-106 mmol/L
Granulosit 12.21 2.50-7.00 ribu/ul
ribu/ul
Limfosit 1.20 1.25-4.00 ribu/ul
ribu/ul

FBS 116 <200 mg/dl

mg/dl
PPBS 124
mg/dl
LABORATORY LABORATORY LABORATORY
FINDINGS FINDINGS FINDINGS
(25-03-2019 / 07:55) (28-03-2019) (28-03-2019)

LAB VALUE LAB VALUE LAB VALUE

Hb 11.2 Hb 11,6 Ureum 148

Leukosit 11.100 Leukosit 11.800 Creatinine 3.60

Trombosit 301 Trombosit 285.000
Granulosit 9.69 Natrium 134 Meq/L
ribu/ul
Limfosit 0.98 Albumin 2,5 g/dl Kalium 4.4 Meq/L
ribu/ul
FBS 145 mg/dl Chlorida 108 Meq/L

PPBS 165 mg/dl

 Planning Monitoring
Cue & Clue Problem Initial Planning Planning &
List Diagnose Diagnose Therapy Planning Education

Mr. A/ 48 y.o/ 1. Diabetic foot Wound bed Mechanical control: Monitor vital sign TD,
Ax pedis S PEDIS culture and Pressure control HR, RR, Tax, SpO2
Wound at left ankle since 5 days ago grade III sensitivity test Wound pus production
Wound getting bigger with yellowish pus and smelly odour. wagner 3 Metabolic control: and odour,
Wound feels pain 2. Diabetic food Pedis Ro sc levemir10 IU at night
History of DM since 10 years ago pedis D PEDIS Monitor the neuropathy
grade I wagner Vascular control: Monofilamen test
Px 1 High intensity statin after there data
GCS: 4-5-6 VAS 4 about lipid profile Educate the patient and
TD: 130/90 mmHg / HR: 98 bpm And antiplatelet the family abut px
RR: 20 tpm / T: 36.7 C SpO2 98% (in air temp) disease, the complication
Educational control and the need of support
R. Foot Sinistra : Pulsation (+) at A. dorsalis pedis and A. tibialis How to care the wound from the family since the
post. wound form 2 hole Φ 1-2 cm, eritematosa with superficial treatment would be long
ulcus in outside hole Depth : base need futher evaluation , Infection Wound control: and demanding
: redness (+), warmth (+), pus (+) yeloowish, edema (-), ABI score Wound toilet
0.91 sensory loss (-)
R. Foot Dextra : pulsation (+), at A. Dorsalis pedis and A. Tibialis Microbiological control:
Inj Ceftriaxone 2 x 1 gr
posterior. Wound form eritematosa at superficial skin or subcutan,
Inf Metronidazole 3 x 500 mg
warmth (+), paint (+), tenderness (+), sensory loss (-), ABI score
0.96

Lab :
DL : 13.2/23.700/262.000
Gds : 236 (at ward)
Alb : 2.6
 Planning
Cue & Clue Problem Initial Planning Planning Monitoring &
List Diagnose Diagnose Therapy Planning
Education
Mr. A /48 yo 2. Diabetes 2. Diabetes Bed rest Monitor
Melitus Type 2 Melitus Type 2 complications
ax IVFD Nacl 0.9% 20 tpm
The patient had a diabetes melitus FBG/ 2PP
since 10 years before admission, Inj Levemir 10 iu sc Urinalisis
and the patient seldom to check up Hba1c if possible
his blood glucose level, not Lipid profile
controlled routinely to the doctor.
The last time (about 2-3 months) he calculate ascvd
control about his diseasse to the score
doctor, he get insulin 10 IU once
daily before sleep, but not injected Educate the patient
everyday. and the family
about px disease,
px and goal in
GCS: 4-5-6 treatment, to
prevent the micro
TD: 140/90 mmHg / HR: 98 bpm
and macro
RR: 20 tpm / T: 36.7 C complication, so the
patien can still have
Gds : 236 a good quality of
Alb 2.6 life
 Planning
Cue & Clue Problem Initial Planning Planning Monitoring &
List Diagnose Diagnose Therapy Planning
Education
Mr. A /48 yo 3. hipoalbumin 3.1 dt diabetic Bed rest Subjective, oedema,
ulcers Albumin recheck
ax 3.2 katabolism PO Channa 3x1 after 3-5 days
Wound at legs since 5 week ago state
Wound getting bigger with Vital sign,’
yellowish pus and smelly odour

px
GCS: 4-5-6
TD: 140/90 mmHg / HR: 98 bpm
RR: 20 tpm / T: 36.7 C

Alb 2.6
 Planning Monitoring
Cue & Clue Problem Initial Planning Planning &
List Diagnose Diagnose Therapy Planning Education

Mr. A /48 yo Renal Impairment 4.1 Chronic Kidney USG renal Bed rest Subjective,
Proteinuria Disease Vital sign, Renal
ax DM II 4.1.1 Diabetik EKG Diet renal with salt restriction low protein 0.6- Function Test recheck
Wound at pedis S since 2 week ago HT Nefropati 0.8 mg/kgbb/ day after 3 days
Wound getting bigger with yellowish pus Hiperurisemia 4.1.2 Obstructive Ro Thorax Urine production
and smelly odour Uropathy IVFD NaCl 0,9% 500 cc/24 jam calculate /24 hours
DM history about 10 years 4.1.3 HT Renal Biopsy Balance Fluid
The patient had a history about high level nefrosklerosis
of uric acid and pain in the left toe and 4.2 Akut on Chronic
he usually use herbal medicine fo his Kidney Disease Educate the patient
paint for 2 years ago about how the renal of
the patient can occur
px decrease of funcion,
GCS: 4-5-6 According to history of
the patient who have
TD: 140/90 mmHg / HR: 98 bpm
DM type 2 and HT, we
RR: 20 tpm / T: 36.7 C suggest the patient to
Cor : LHM ~ ictus, RHM ~ SL (D) control the blood
pressure and blood
DL : 13.2/23.700/262.000 glucose routinely to
UL : maintenance the renal
Protein Albumin +2 function
Glukosa +1
Ur/Cr 188/3.95
eGFR 19
Uric Acid : 10.7
 Planning
Cue & Clue Problem Initial Planning Planning Monitoring &
List Diagnose Diagnose Therapy Planning
Education
Mr. A /48 yo 5. HT stg 1 Candersartan 1 x 8 mg Subjective,
Blood Pressure
hypertension since 10 years ago, not Dietary low salt restriction should check
controlled routinely routinely
EKG
History antihypertensive drug
Ro Thorax

Educate to the
GCS: 4-5-6 patient that he have
TD: 140/90 mmHg / HR: 98 bpm to check the blood
RR: 20 tpm / T: 36.7 C pressure routinely
to avoid other
complication
C / s 1 s2 single m- g -, ictus
palpable at MCL S, heart margin at
normal place
 Planning
Cue & Clue Problem Initial Planning Planning Monitoring &
List Diagnose Diagnose Therapy Planning
Education
Mr. A /48 yo Hiperurisemia 6.1 Arthritis Gout Paracetamol 500 mg Subjective,
Pain in stadium acute Codein 10 mg Blood Pressure
The patient had a history about high Metatarsal-1 Pulv 3x1 should check
level of uric acid and pain in the left Sinistra routinely
EKG
toe and he usually use herbal
Ro Thorax
medicine fo his paint for 2 years
ago Educate to the
Pain in the toe S patient that he have
to check the blood
GCS: 4-5-6 pressure routinely
TD: 140/90 mmHg / HR: 98 bpm to avoid other
complication
RR: 20 tpm / T: 36.7 C
Swollen in the toe (-)
Pain in the ankle dextra et sinistra

Uric Acid 10.7

 Problem Analysis
Diabetes
mellitus
Vascul
ar
HT stg 2
proble
m
Diabetic
foot Wound Hipoalbum
infection loss inemia
(wound)
Hyper
Anemia
katabo
Normochro
lic
me
state
normociter
 RISK FACTOR ANALYSIS
PROBLEM THEORY FACTUAL

Risk Factor of DM Type II

• Family history of diabetes

• Overweight
• Unhealthy diet
• Physical inactivity On This Patient
• Increasing age Physical inactivity
DM type II
• High blood pressure Increasing age
• Ethnicity
• Impaired glucose tolerance (IGT)*
• History of gestational diabetes
• Poor nutrition during pregnancy

International Diabetes Federation

150 150

145 145
145 145

145
150 0.96
Left ABI = 0.96
145 0.96 Right ABI = 0.96
150
Benjamin A. Lipsky. Et al 2012. Infectious Diseases Society of America
Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infec
IDSA Guideline for Diabetic Foot Infections • CID 2012:54
Benjamin A. Lipsky. Et al 2012. Infectious Diseases Society of America
Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infec
IDSA Guideline for Diabetic Foot Infections • CID 2012:54
PEDIS CRITERIA
Date:
WAGNER CRITERIA
Date:
MANAGEMENT OF DIABETIC
FOOT
 mechanical control-pressure control
 wound control
 microbiological control-infection control
 vascular control
 metabolic control
 educational control
PRESSURE CONTROL
Underpresured wound will never be able to heal
Px was given rehab or with the help of devices eg: Removable cast walker,
Total contact casting, Temporary shoes, Felt padding, Crutches, Wheelchair,
Electric carts, Craddled insoles.
Few surgical procedure can also help to reduce pressure: decompression
with abcess incission, metatarsal head resection, Achilles tendon
lengthening, partial calcanectomy
OFFLOADING
Microbiological control
in Cipto Mangunkusumo hospital Jakarta, generaly multimicrobial pattern
was found, the combination on gram positive, negative and anaerob bacteria
was found in the infected and smelly

Because of that reasen the choice of antbiotic should be the one that has
large coverage (third gen cefalosporin as an example), combined with one
that has coverage for anarob bacteria ( metronidazole

Papdi VI 2014 2367-2371

WOUND CARE
 Debridement, aimed at removing debris, eschar, and surrounding callus .
Sharp (or surgical) methods are generally best. but mechanical, autolytic,
or larval debridement techniques maybe appropriate for some wounds
 Selection of dressings that allow for moist wound healing, and control
excess exudation. The choice of dressing should be based on the size,
depth, and nature of the ulcer (eg, dry, exudative, purulent)
 do not use topical antimicrobials for treating most clinically uninfected
wounds

Benjamin A. Lipsky. Et al 2012. Infectious Diseases Society of America

Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infec
IDSA Guideline for Diabetic Foot Infections • CID 2012:54
DRESSING
The principal function of a wound dressing is to help achieve an optimal
healing environment
The goal is to create a moist wound environment to promote granulation
(new tissue containing all the cellular components for epithelialization),
autolytic processes (wherein host generated enzymes help break down
devitalized tissues), angiogenesis (new blood vessel formation), and more
rapid migration of epidermal cells across the wound base
if dry, it should be hydrated if draining, the exudate should be absorbed if
necrotic, it should be debrided
 Continuously moistened saline gauze: for dry or necrotic wounds
 Hydrogels: for dry and or necrotic wounds and to facilitate autolysis
 Films: occlusive or semiocclusive, for moistening dry wounds
 Alginates: for drying exudative wounds
 Hydrocolloids: for absorbing exudate and to facilitate autolysis
 Foams: for exudative wounds
 KEY MESSAGE PATHOPHYS

Ralph A. DeFronzo. From the Triumvirate to the Ominous Octet: A New Paradigm for the
Treatment of Type 2 Diabetes Mellitus. Diabetes. 2009; 58: 773-795
KEY MESSAGE
MANAGEMENT
 The evaluation of a Diabetic foot infection should occur at 3 levels: first the
patient as a whole, then the affected foot and limb, and finally the wound
KEY MESSAGE SOCIAL
 The support from the family is important for the patient since the
treatment will be long and complicated.
TERIMA KASIH