DIABETIC FOOT

By : PRISCA YULIANI SUBAN

(C11108 226)
SUPERVISOR :
dr.Husaini Umar,Sp.PD.KEMD
SUB-DIVISION OF ENDOCRINE AND
METABOLIC
MEDICAL FACULTY
HASANUDDIN UNIVERSITY
Patient Identity
Name : Mrs.K
Age : 56th
Medical Record Number : 77 73 44
Adress : Makassar
Date of Hospital Admission : 2 November 2016
Hospital : Wahidin Sudirohusodo
Date of inspection : November 7th, 2016
Anamnesis
Main Complaint : On the right leg wound finger
The wound on the right foot suffered since at least
the last 2 weeks, the wound was initially small and
increasingly enlarged accompanied by pus and
smells. A history of foot ulcers cause patients is
unknown, patients also complain sometimes
patients feel cramps in his legs. One week ago have
performed operations (debridement) in the legs of
patients in Wahidin hospital. A history of diabetes in
patients with no known past two years, however,
patients do not take medication regularly and
frequently consume potions made by his own self at
the instigation of others.
 No fever, no history of fever, dizziness no, no
headache. Patients also complained of frequent
fast hungry, thirsty and when frequent night
waking to urinate. No cough, no shortness of
breath, chest pain history does not exist. No
heartburn, nausea and vomiting does not exist.
A history of defecate felt no change frequency,
consistency, and color. History urinate is felt
smooth clear yellowish color.
Past Medical Story
Hypertension history denied
History Heart disease does not exist
No DM history
Family History
Patients unmarried
Sick of the same history in the family does not
exist
DM in the family is not known
History of hypertension in the family did not go
unnoticed
Physical Examination
Weight : 55kg, Height : 160cm, BMI : 20,8
kg/m2
Vital sign :
Blood pressure : 110/70 mmHg
Heart rate : 88 time per minute
Respiratory rate : 20 time per minute
Temp : 36,5 C
General description :
Impression pain: Pain Medium
Awareness: Composmentis
 Physical examination :
GCS: E4 M6 V5
Head: normocephal, straight black hair
Eyes: no conjunctival pallor,no jaundice sclera
Neck: JVP did not increase the position of 30 , no
lymphadenopathy
Thorax : I: Asymmetrical left and right
Q: Tenderness no, no tumor mass
P: Sonor left and right
A: vesicular breath sounds and wheezing
Ronchi no
Heart: I: Ictus cordis does not seem seem
Q: Ictus cordis palpable at ICS IV linea
medioclavicularis sinistra
P: Right margin on ICS II linea parasternalis
dextra
Bottom right border ICS IV linea
parasternalis dextra
Top left border ICS II linea parasternalis
sinistra
Bottom left border of the left
medioclavicuaris ICS IV
A: heart sound I / II regular pure, no heart murmur
Abdomen: I: flat, follow the motion of breath
A: normal intestinal peristaltic
impression.
P: liver and spleen not palpable
Q: normal tympanic
Extremities : Akral warm, Oedema no. In dextra
pedis obtained swathed in elastic bandages with
the surface of the bandage was no blood, the
smell of the wounds suggest no.
Support Examination
WBC :22.600 NEUT 65,2 HB:13,1 MCV:79 MCH:32,2
PLT:237.000 GDS: 396 UREUM:32 CREATININE:0,75 SGOT:42
SGPT: 35, Na : 138 K: 4,0 Cl: 106 PT : 13 APTT 24,9 HBA1C : 13

Photo Pedis dextra: Looks gas gangrene pedis

and distal cruris dextra
The list of issues
1. Diabetic foot Wagner 4
Diagnosis based their complaint on pedis dextra
injuries experienced since the last 2 weeks, pus
and odor, and has performed debridement in OK,
the physical examination found pedis dextra
swathed ferban impression no bleeding. In
investigations obtained leukocytosis with
hyperglycemia in radiology X-ray examination
pedis dextra dextra gas gangrene and distal cruris
pedis. In our patients with the diagnosis of
diabetic foot wagner 4 in which the patients had
their wounds with a history of DM and on imaging
studies obtained their gas gangrene.
 Diagnostic Plan:
- Bacterial culture and sensitivity of the AB
blood and pus
Treatment Plan:
- 0.9% NaCl flush 20 drops / minute intravenous
- Ceftazidime 1 g / 8 hours / IV
- Metronidazole 500mg / 8 hours / IV
- Ciprofloxacin 0,2gr / 12 / IV
2. Diabetes Mellitus type II
Diagnosis based on their history of diabetes are
unknown since the last 2 years, and did not
take medication regularly. In patients also
obtained triad DM (Polidipsi, Poliurui and
Polifagi). In investigations obtained GDS 396
and HbA1c 13. Thus in our patients think
Uncontrolled diabetes
Diagnostic Plan
- Monitoring GDS Morning, Afternoon, Evening
(before eating)
Treatment Plan
IVFD NaCl 0.9% 20 drops per minute
- Novorapid 6-6-6 iu / subcutan before eating
- Levemir 10 units of night 22.00
DIABETIC FOOT
Classification Wagner
Grade 0: no lesions, skin still intact with
possibly with foot deformity
Grade I: superficial ulcers confined to the skin
Grade II: penetrating ulcer in the tendon and
bone
Grade III: abscess in, with or without
osteomyelitis
Grade IV: gangrenous toes or feet with the
distal part or cellulitis
Grade V: gangrene whole leg or part of leg
Pathomechanism occurrence of
diabetic foot,depending on 3 factors:
Vascular : blockage of blood vessels due to
atherosclerosis -> ischemia -> gangrenous
Neuropathy :
sensory -> interference sensibility that does not
feel pain -> repetitive trauma -> ulcer
motor: change the fulcrum -> foot deformities ->
repetitive trauma -> ulcer
autonomous -> dry skin and has a fissure -> ulcer

Infection
Treatment of Diabetic Foot
1. Antibiotic -> based on the culture of bacteria
causing the infection. But in the given Triple
Blind Therapy before culture results come out
for gram-negative bacteria -> class
Quinolones
for gram-positive bacteria -> group
Cephalosporin
for anaerobic bacteria -> Metronidazole
2. Incision and drainage
3. Soft tissue, joint and bone resection
4. Amputation
DIABETES MELLITUS
Definition
A group of metabolic diseases with characteristic
hyperglycemia that occurs because kelaianan
insulin secretion, insulin action, or both
Classification
Clinical Symptoms
Classic Other
symptoms symptoms:
of diabetes: - Weak body
- Polidipsi - Pins and needles
- Polyuria - Itchy
- Polifagi - Eyes blurred
- Weight loss that - Erectile disorders in
can not be men
described it - Itching in the pubic area
in women
Criteria for the diagnosis of DM
Management
1. Education
DM understanding, promotion of healthy living, blood glucose
monitoring, the signs and symptoms of hypoglycemia
2. Medical Nutrition Therapy
DM diet regulatory principles: a balanced diet according to the
needs of calories and nutrients gisi each patient, as well as the
regularity of schedules, the type and amount of food.
3. Physical activity
4. Pharmacologic therapy
ADO divided 5 groups:
- Triggers secretion of insulin: Sulfonylurea (Prev meal consumed
15-30 minutes) and glinid (momentary Prev meal)
- Improved insulin sensitivity: metformin and thiazolidinediones
- Metformin
- Abs glucose inhibitors: inhibit alpha-glucosidase
- DPP-IV inhibitor