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Blame it on the “tack”. . .

Blame it on the “tack”. B3B: Dr. Marilyn Ong - Mateo Fajardo , Revie ; Fang, Mark; Florendo , Gerard; Fontano, Michael; Francisco, Theres e; Gabuat , Harry; Gaffud , Bianca; Gagtan , Majelle ; Gallardo, Heart; Garan , Aileen; Garcia, Cholson ; Garcia, Louise; Garcia, Irka. HISTORY.

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Blame it on the “tack”. . .

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  1. Blame it on the “tack”. . . B3B: Dr. Marilyn Ong - Mateo Fajardo, Revie; Fang, Mark; Florendo, Gerard; Fontano, Michael; Francisco, Therese; Gabuat, Harry; Gaffud, Bianca; Gagtan, Majelle; Gallardo, Heart; Garan, Aileen; Garcia, Cholson; Garcia, Louise; Garcia, Irka

  2. HISTORY

  3. General Data • A.B • 49/M • Filipino • Roman Catholic • Paranaque City • Married • Fruit Vendor • Date of Admission: Nov 9, 2009

  4. Chief Complaint * Painful swelling of the left foot (heel) *

  5. AB: 49/M known diabeticHistory of Present Illness

  6. AB: 49/M known diabetic x 12 yearsHistory of Present Illness

  7. Past Medical History • Immunizations: unrecalled; BCG • Hospitalizations: • non-healing wound : unrecalled antibiotics (1997) • Hemoptysis- CXR: PTB; Rx: MyrinForte (HRZE) 6 months (approx. 5 yrs ago) • Diabetes Mellitus (1997) • Medications: Glibenclamide500mg OD • No surgery • No allergies

  8. Personal and Social History • 16 pack year smoking • Alcohol drinker 2 bottles of beer/night • Mixed diet ; cautious with sweets • Exercise: sidecar (padyak) in selling fruits • Sleep:4-6 h/day

  9. Family History • (+)DM: sister- deceased due to ‘heart attack’ (52 years old) • Father - deceased- sudden death(age?) • (+)cataract: mother • (-) asthma, HPN, CA

  10. Review of System GENERAL SURVEY: ( - ) fever ( - ) weight loss ( - ) weakness ( - ) fatigability ( - ) malaise SKIN: ( +) 3 inch-scar on the lateral aspect of the left leg ( - ) itchiness ( - ) color change ( - ) rash HEENT: ( - ) icterus ( - ) ear pain/ discharge ( - ) nasal discharge ( - ) deafness ( - ) lymphadenopathy PULMONARY: ( - ) dyspnea ( - ) shortness of breath ( - ) cough ( - ) sputum production ( - ) hemoptysis ( - ) wheezing

  11. Review of System CARDIAC: ( - ) chest pain ( - ) easy fatigability ( - ) paroxysmal dyspnea ( - ) orthopnea ( - ) palpitations ( - ) syncope ( - ) edema ( - ) hypertension GI: ( - ) nausea ( - ) vomiting ( - ) retching ( - ) hematemesis ( - ) melena ( - ) hematochezia ( - ) belching ( - ) distention ( - ) diarrhea ( - ) constipation GU: ( + ) polyuria ( + ) incontinence ( + ) erectile dysfunction ( - ) anuria ( - ) dysuria ( - ) hesitancy MUSCULOSKELETAL: ( - ) rigidity ( - ) flaccidity ( - ) weakness

  12. Review of System NEUROLOGIC: ( - ) numbness ( - ) tingling ( - ) burning ( - ) sharpness ( - ) motor weakness ENDOCRINE: ( + ) polydipsia ( + ) polyphagia ( - ) heat/cold intolerance HEMATOPOIETIC: ( - ) bleeding tendency ( - ) bruisability

  13. Physical Examination

  14. Physical Examination

  15. Physical Examination

  16. Physical Examination

  17. Physical Examination

  18. Physical Examination

  19. Physical Examination

  20. Salient Features 49 y/o male Painful, swollen, erythematous, ulcerated lesion with purulent discharge, left calcaneal area

  21. Salient Features

  22. Clinical Impression • Non-healing Wound, Left calcaneal area • Diabetes mellitus, Type 2, Insulin-requiring

  23. Initial Orders • CBC • Wound secretion gm stain, C/S • FBS, glycosylated hemoglobin • CBG monitoring with sliding scale-directed insulin administration • Chest X-Ray

  24. Laboratory Workups

  25. Laboratory Workups

  26. Laboratory Workups

  27. Laboratory Workups

  28. Question to the group • Do you think there’s a need to establish vascular (arterial) integrity of the lower extremity in this patient? • If yes, what test would you recommend? Arterial Duplex Scan?

  29. Management • Antibiotics given?? • Proper foot care especially among diabetics • Hydration?? • Diabetes management?? CBG Monitoring and insulin therapy?? Dietary instruction??

  30. Final Diagnosis • ???? • Take home instructions and medications

  31. Succeeding slides should focus on the following: • Why diabetics are prone to develop non-healing wounds • What microorganisms are usually involved • Journals- any new updates on wound care and treatment of non-healing wounds among diabetics. Please search local journals also. AFTER ABOVE- FINISH!!! The rest of your beautiful slides- HIDE! HIDE! HIDE!

  32. Laboratory Workups

  33. 49 y/o Male, DM2 • (+) polyuria; polydipsia; polyphagia • Erectile dysfunction • Non-healing wound/ulcer • Grossly inflammed left foot • Decreased pulses of the dorsalis pedis artery

  34. Initial Clinical Impression: history & PE • Non healing wound to consider soft tissue infection secondary to DM2

  35. Laboratory Workups

  36. Laboratory Workups

  37. Laboratory Workups

  38. Laboratory Workups

  39. Secondary Clinical Impression:hisotry, PE, laboratory workups Non healing wound to consider soft tissue infection secondary to DM2

  40. non-healing foot ulcer

  41. Final Clinical Impression: Non healing wound with soft tissue infection secondary to DM2

  42. PATHOPHYSIOLOGY

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