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This walks into your outpatient family med clinic, patient has not brought this to medical attention before. Your MA warns you of the smell before you go in, and she's not wrong. Patient is a pleasant, nonobese female in her early 60s in no acute distress.  It's after hours, and you can draw labs but have no imaging on site.

What, dear PA students, do you do first? You've got no one else in the waiting room at the moment, so you can afford to be thorough.

IMG_20181128_171043.jpg

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5 minutes ago, EMEDPA said:

open a window and find some air freshener for the hallway...

Yes, but I doubt that will be on anyone's boards.

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It's finals week! Give us some time.

History and physical!  See what the patient is feeling, what made them finally come in etc. Diabetes? Would draw labs for sure CBC etc..

As for treating that, my guess would be clean it up and cover. Possible ABX due to infxn?

Sounding like diabetic ulcer to me though and going to need more attention than just this visit.

That's all I've got. Oh and a can of febreeze.

 

Edited by JD2012
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3 hours ago, JD2012 said:

It's finals week! Give us some time.

History and physical!  See what the patient is feeling, what made them finally come in etc. Diabetes? Would draw labs for sure CBC etc..

As for treating that, my guess would be clean it up and cover. Possible ABX due to infxn?

Sounding like diabetic ulcer to me though and going to need more attention than just this visit.

That's all I've got. Oh and a can of febreeze.

 

Same thoughts through my head as well. 

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So yes, this patient IS diabetic, and had a history of poor glycemic control, with an A1c of 10.7 at last visit 2 months ago, and she was started on insulin at that time.

What else do you want to know?  What physical exam are you going to do that might change your management plan? Antibiotics are a good thought--how are you going to decide what to start in an outpatient clinic?

ETA: Oh yeah, and of course it's finals week.  All the most interesting problems and opportunities will always crop up while something else is going on!

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Hmmm.  

Compliance with taking insulin?  For PE, perhaps pin prick and check for neuropathy, especially if the patient isn't reacting to that kind of wound. Palpate? Looking like possible stasis/cellulitis also.

ABX check for PCN allergies, if so, either Macrolides or Bactrim. Leaning towards PO(systemic).

Back to studying for me!  

 

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C&S of the wound for proper coverage, while starting something broad until results come back. And also, WOUND CARE

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16 minutes ago, ak004 said:

C&S of the wound for proper coverage, while starting something broad until results come back. And also, WOUND CARE

Good thoughts. I haven't been back to the office to see what the C&S actually said, but I absolutely ordered it, as well as placing an urgent wound care referral as well.  I'll address what ABX I actually did start in my response to the other post.

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On 12/2/2018 at 5:19 PM, JD2012 said:

Compliance with taking insulin?  For PE, perhaps pin prick and check for neuropathy, especially if the patient isn't reacting to that kind of wound. Palpate? Looking like possible stasis/cellulitis also.

ABX check for PCN allergies, if so, either Macrolides or Bactrim. Leaning towards PO(systemic).

I didn't actually ask insulin compliance.  Overall diabetic control obviously wasn't sufficient, but I didn't see any point in a "We told you so" line of questioning, and past compliance won't help going forward. Also, no matter what she says, it's not going to change my treatment going forward.

Patient is still sensate in the affected foot, and in fact is exquisitely tender to palpation everywhere around the wounds--all the erythematous areas hurt.

It's definitely cellulitis--you can tell that just by looking at it.  There are two things I am acutely worried out; sepsis is one of them, but while she was tachycardic and arrhythmic, she was not hypotensive, not tachypneic, and normothermic, and there are no streaks extending proximally. It's not an acute infection, of course, and has been getting this way for a month.

Follow-up questions:
- What is the other thing, besides sepsis, I am worried about for this foot?  How do I check for it?
- Tachycardia and arrhythmia? What do I do about that in an outpatient setting?
- Consult your guides!  I can (and did) start aggressive outpatient (PO/IM) antibiotics while awaiting further workup.  What do you think I SHOULD have started?
- Aside from the wound cultures, what bloodwork would you order and why?
- What other interventions or investigations, not mentioned here or in previous comments, would you start?

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Nice case and the pic really brings it home.  We see this at least once a day in my ED too!  For those of you who are lost, haven't studied or seen these patients before, here is a great review from an EM perspective for those who happen to have access to EM:RAP 

 

https://www.emrap.org/episode/emrapdecember/diabeticfoot

 

If none of you students have access to this, let me know and I can copy/paste the show notes since they provide a really nice summary, once Rev has finished the case.

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Had a similar case recently...are non students allowed to chime in yet??

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I would be concerned for osteo, get plain films to begin with. If not apparent on plain films, I would MRI the foot. Just got accepted to a program, so not sure on abx coverage, would be concerned for diabetic nephropathy, so would have to consider renal function.

Edited by rabothe3
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1 hour ago, rabothe3 said:

I would be concerned for osteo, get plain films to begin with. If not apparent on plain films, I would MRI the foot.

Yep.  Plain films showed suspicions in at least 4 separate bones, so MRI was ordered for follow-up.

 

2 hours ago, MCHAD said:

Had a similar case recently...are non students allowed to chime in yet??

I'd really rather a few others answered my questions before all of us practitioners dissect things.

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Follow-up questions:
- What is the other thing, besides sepsis, I am worried about for this foot?  How do I check for it?
- Tachycardia and arrhythmia? What do I do about that in an outpatient setting?
- Consult your guides!  I can (and did) start aggressive outpatient (PO/IM) antibiotics while awaiting further workup.  What do you think I SHOULD have started?
- Aside from the wound cultures, what bloodwork would you order and why?
- What other interventions or investigations, not mentioned here or in previous comments, would you start?

 

My brain is fried at the moment, just finished number 6 of 7 final exam in the past week and today was pharmacology. 😞

Check venous flow via doppler? Her leg/foot looks plump/edematous. But I would be suspicious of venous or lymphatic flow.

If she isnt hypotensive perhaps a CCB for the arrhythmia.

I am lost for the moment on the other things but due to being mentally drained for now.

 

 

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Checking lower extremity vascular sufficiency with an ankle/brachial index would have been one option.  I didn't end up doing that, but it's one of the things I found myself wishing I had taken the time to do.

As far as the tachycardia and arrythmia goes, the first thing I did was order an EKG, which showed frequent PVCs on top of NSR.  Since she was asymptomatic, I placed a cardiology consult, figuring that she would need one before any eventual surgery even if it wasn't her most pressing problem.

OK, the open/remaining questions are lab work (what & why) and outpatient antibiotics.

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In regards to labs, I would think run a CBC with ESR and a CMP with CRP, look for immune response, renal function. In regards to outpatient abx, perhaps Bactrim and Keflex for broad coverage until cultures were returned but statistically this is like staph or strep spp. cipro would not be bad choice to cover for gram (-) bugs; however, I would not be surprised if pt failed outpatient therapy and required IV vanc and rocephin.

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2 hours ago, rabothe3 said:

In regards to labs, I would think run a CBC with ESR and a CMP with CRP, look for immune response, renal function. In regards to outpatient abx, perhaps Bactrim and Keflex for broad coverage until cultures were returned but statistically this is like staph or strep spp. cipro would not be bad choice to cover for gram (-) bugs; however, I would not be surprised if pt failed outpatient therapy and required IV vanc and rocephin.

Good on the labs.  I ordered all of those, plus a TSH and an A1c because those were done 2 months ago and problematic, and I wanted to see how they had changed since.  I also ordered blood cultures, just in case, but in retrospect that was probably overly cautious.

I agree that IV antibiotics are indicated in this case, but my gut made the call that I wasn't going to be able to get her to go and get admitted that night, and I don't have IV support.

Based on the Sanford guide, (p. 17, 2018 edition) I went with Augmentin and Doxycycline.  I seem to recall she was Sulfa-allergic, but don't have the chart in front of me. We DO have Rocephin (Ceftriaxone) available so I had her given 1 gm IM before she left.  Keflex is one of the other options, and would have been reasonable given no history of MRSA.  I went with Augmentin in part because of the less frequent dosing--bid for Augmentin, qid for Keflex.  When in doubt, go with the easier med for patient compliance.

OK, that pretty much wraps up what I wanted students to comment on.  Practicing PAs, feel free to pick it apart.

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I think BC was a good idea along with a lactate and CRP/sed rate. they will need them when the pt is admitted....

augmentin and doxy is great coverage, gets you a multitude of bugs including mrsa and anaerobes. not great for pseudomaonas, but they will probably get zosyn as an inpt to cover that at the time of surgical exploration/debridement/possible amputation....

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40 minutes ago, rev ronin said:

Good on the labs.  I ordered all of those, plus a TSH and an A1c because those were done 2 months ago and problematic, and I wanted to see how they had changed since.  I also ordered blood cultures, just in case, but in retrospect that was probably overly cautious.

I agree that IV antibiotics are indicated in this case, but my gut made the call that I wasn't going to be able to get her to go and get admitted that night, and I don't have IV support.

Based on the Sanford guide, (p. 17, 2018 edition) I went with Augmentin and Doxycycline.  I seem to recall she was Sulfa-allergic, but don't have the chart in front of me. We DO have Rocephin (Ceftriaxone) available so I had her given 1 gm IM before she left.  Keflex is one of the other options, and would have been reasonable given no history of MRSA.  I went with Augmentin in part because of the less frequent dosing--bid for Augmentin, qid for Keflex.  When in doubt, go with the easier med for patient compliance.

OK, that pretty much wraps up what I wanted students to comment on.  Practicing PAs, feel free to pick it apart.

that is fair and something I will definitely remember. thank you for positing this, great exercise.

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16 minutes ago, EMEDPA said:

I think BC was a good idea along with a lactate and CRP/sed rate. they will need them when the pt is admitted....

I considered lactate, but the patient appeared hemodynamically stable, PVCs being the sole concern. Had I been treating her inpatient or ED and I could have gotten it stat, I would have.  Had she actually met sepsis criteria, I would have called the FD and let her sign AMA with the EMTs.

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Just a side point: this is a patient that could show up anywhere, uc, fp, Ed, etc.  While I certainly understand studying is important, but when you get to the real world, this will be the eleventh patient of the day, you haven't eaten because you charted during lunch, and the previous ten patients included COPD exacerbations with diabetes, chfer who gained six pounds over night, a fellow on warfarin with a "UTI" who fell last night...

You are not going to be called when you are at your best, but you will be expected to act like you are.  

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