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holistic management plan

Discussion in 'Diabetic Foot & Wound Management' started by Suzsi, Nov 17, 2010.

  1. Suzsi

    Suzsi Member


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    Case study

    62yr male with type 2 diabetes. controlled with combo of metformin, glicazide and insulin. recent HnA1c was 14%.

    Some digits amputated from right foot 21 yrs ago due to ulceration and infection. He has current plantar ulceration on right foot over 5th met head (40mm width). Had it for 18 mths with no pain.
    tissues inflammed and heavily callused.
    wound base shows granulation tissue, surrounding tissue sometimes macerated.
    Probe - shows no bone

    Also has iron def anaemia and taking ferrous sulphate.
    Suffered MI 5 yrs ago.
    Has 2ndary hypertension, prescribed Atenolol and Nifedipine.
    Hyperlipidaemia and takes lipid lowering drugs.
    Lives alone.
    Likes to walk into town to see friends.
    Current smoker 3-4 per day (used to smoke 20 per day)

    required to develop holistic management plan considering wider implications of wound and complexities of diabetes.
     
  2. drsarbes

    drsarbes Well-Known Member

    Type 2 taking insulin?
     
  3. Suzsi

    Suzsi Member

    Yes, but doesn't say which one
     
  4. WApod

    WApod Member

    My Management plan of this patient would include the following...

    Sounds like this guy really needs multidisciplinary foot ulcer team management - if you have one close to you refer him on if thats not possible this should give you an indication of what is needed. Keep the GP informed.

    Diabetes - With such an elevated HbA1c he is at great risk of infection and healing will be very slow (not to mention all the other complicatins of diabetes). Priority would be to see an Endo to try and improve his control. If he self monitors his BGL get him to do a 3 day profile (include test first thing in the AM before food, then before and 2 hrs after each meal and at bed time) also write down what he eats / drinks and any activity he does and take it along to the specilaist or Diabetes educator. This will give a good indication on what improvements are needed. May need to see a diabetes educator or Dietician too epending on his BGL profile.

    Arrange Blood tests with GP or specilaist - check inflamatory markers, WBC, Cholesterol and renal function in particular.

    Wound it self will need good, regular debridement + Suitable dressing. If he lives alone arrange for home visit or practice nurse to dress it for him. Offloading is essential preferably a walker and a customised accomodative orthotic if he can cope with it. If no infection and no PVD consider a TCC. Maybe suggest a motorised scooter for him to get into town rather than walking, if thats not possible or he's very unsteady - Wheelchair.

    Check his vascular status. If ABPI or toe pressures are low refer to vascaular for oppinion and management - If he does need Antibiotics the circulation needs to be good for them to reach the area and also need to heal a wound esp if any surgery is needed.

    When you say "probe - shows no bone" do you mean that Bone can be probed but not seen? If this is the case he probably has osetomeylitis. X ray / Bone and white cell scan or MRI would be advised ASAP. If there are any changes to the Bone he will probably need IV antibiotics + orals for a long time + / - surgery to get it to heal. Also take a deep swab or a tissue sample for culture and sensitivity. If the bugs grown are complex, unusual or resisant get a microbiologist's oppinion on preferred Ab therapy and delivery method. If he hasn't had any Antibiotics for a while and there are obvious changes on xray consider if a bone biopsy of the area is possible.

    Also make sure you have a good chat with the patient and see how he feels about all this. MAke sure he understands what's going on and what's at risk and what his responsibility is in helping his foot. Make sure he is involved with all decision making and that this is going to take a long time!! Consider councelling if he is depressed, anxious or upset, maybe get clin physc or social workers involved if he's situation is very complex.

    That should give you enough to be going on with!
     
  5. Suzsi

    Suzsi Member

    Hi,
    I'd just about covered all bases. The 'no bone' probe - ulcer is granulating and probe done but nothing felt other than flesh.

    Thanks very much
     
  6. Is this a real patient or a student assignment? This: "develop holistic management plan considering wider implications of wound and complexities of diabetes." sounds like an assignment to me?
     
  7. Suzsi

    Suzsi Member

    Real patient but with false added complexities. Been asked to think outside the box. I understand we are not to ask about case studies - so this should be withdrawn. My apologies for wasting time.
     
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