Things not to miss - Diabetic foot



An elderly man with long standing diabetes mellitus was followed up at a medical clinic. His blood sugar values and blood pressure recordings were as follows.

 March 2019
  • FBS - 180mg/dL
  • PPBS - 210mg/dL
  • BP - 170/110mmHg
April 2019
  • FBS - 155mg/dL
  • PPBS - 190mg/dL
  • BP - 160/100mmHg
May 2019
  • FBS - 150mg/dL
  • PPBS - 176mg/dL
  • BP - 150/90mmHg

Happy??
  • Certainly yes! Blood sugar values were slowly but improving. Blood pressure was also getting better.
In June 2019 patient admitted with fever, right leg swelling and pain. Patient was confused, there was tachycardia and low blood pressure.


Clinical diagnosis?
    • Cellulitis causing sepsis with shock.


How are you going to resuscitate?
    • Recall the sepsis BUNDLE!
    • In summary
      • Hydrate
      • Inotropes - Preferably Noradrenaline
      • Take cultures
      • Start appropriate IV antibiotics
      • Control blood sugar with insulin (140-180mg/dL)
      • Treat empirically for DVT, if excluded give prophylaxis.
      • Get help from surgical team

His foot examination revealed..
  • Fungal infections in several web spaces.
  • Multiple heel cracks
  • Callosities and cones
  • Paronychia
  • Sensory neuropathy up to knee
  • Absent dorsalis pedia pulses
Unfortunately due to spreading uncontrolled infection BK amputation had to be done.


 Answer the question in RED again?


 Could you have prevented the amputation?
  • YES!

Diabetes and foot.
  • Patient education is pivotal.
  • At every opportunity examine the foot.
Things to look for
  • Circulation - Pulses
  • Nerves - Check sensations
  • Skin - Dryness, scaling, cracks
  • Deformities
  • Proper footwear
    • Good space for toes
    • Cotton socks - Change daily
  • Callosites and cones
    • Take the help of surgical team early.
    • May need modified footwear.
  • Ulcers
  • Toenails 
    • Trim nails along the shape of the tow
    • Never cut up to cuticle
    • Ingrown toenails
    • Paronychia
What is this?

  • Web spaces - Fungal infections
    • Treat with topical antifungal. eg: miconazole. Advice patients to keep web spaces dry.
      What is this?
Encourage people to self-examine foot. A mirror has to be used to inspect the areas which are difficult to visualize.

For those who are unable, educate the caretakers.

Ask patients to take IMMEDIATE medical advice if there is
  • Blisters
  • Swelling
  • Redness etc.
Sometimes, due to neuropathy they might not feel the pain. So any fever could be cellulitis!

Remember, in diabetics, CELLULITIS is a KILLER.

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