Diabetic Ulcer Question

[mgriffiths]

So this is a medical question that is squarely based off a patient I see.  Patient is a relatively new patient to my practice - uncontrolled DMII with history of bilateral great toe amputation due to chronic infections.  While his A1c has not yet become normal, we have made significant progress.  Started at 13.2 and 1 month later was 10.8 (I know A1c is a 3 month test, but I like to give patients hard data showing improvement), so again...significant progress has been made in a short time.  Unfortunately he came to me with a plantar 1st MTP joint ulcer.  He was urgently referred to wound care and ultrasound and followup MRI were done to rule out deep abscess and/or osteomyelitis.  He was recently discharged from wound care stating the ulcer had healed...but they did no imaging to confirm anything was deep to the superficial callous formation at ulcer site.  Patient continued to be tender to palpation at location.

Now, I am NOT a wound care specialist, but feel this patient should have had an ultrasound to confirm complete resolution...both superficial and deep.  Am I correct or is this considered unnecessary?

Not that it necessarily changes anything, but patient developed a draining lesion with streaking cellulitis lateral aspect of same lower extremity approximately 5cm inferior to knee.  From my experience I am extremely worried the patient's infection was never fully cleared and has now spread putting him at risk for BKA. Labs, imaging, and antibiotics started...but needless to say I'm frustrated.

 

As a follow up...anyone know or can give direction on what it takes to be come "wound care certified" as a PA?

Edited June 17, 2019 by mgriffiths

[Arthropathy]

If you are concerned you should order follow up imaging such as MRI. Sounds like a reasonable concern and plan. If no abcsess or osteomyelitis then you have documented proof no need for further intervention.

[mgriffiths]

Yep, I ordered US, XR, labwork, vascular referral, etc. today...started antibiotics.  I was more just HUGELY surprised wound care did nothing to confirm that ulcer was gone with no abscess formation deep since patient was still tender - so was wondering if that was wound care protocol or more normal to have confirmatory US.

[Arthropathy]

Maybe just a different level of comfort given their specialty

[ventana]

ESR and CRP will tell you if the infection is still brewing (actually normal would say it is not there - but nonspecific) 

elevated levels show that something somewhere is brewing.... but not confirm the infection....

 

imaging is reasonable - would not really do US but maybe MRI

[mgriffiths]

Yeah, CRP was sky high while ESR was normal...definitely has at minimum cellulitis.  From workup so far just appears to be cellulitis, but has been referred to vascular and they will get MRI as they can get completed faster than FM...

[SedRate]

20 hours ago, mgriffiths said:

He was urgently referred to wound care and ultrasound and followup MRI were done to rule out deep abscess and/or osteomyelitis.

Any results from MRI? I don't think the ultrasound would be useful. 

20 hours ago, mgriffiths said:

uncontrolled DMII with history of bilateral great toe amputation due to chronic infections.

 

20 hours ago, mgriffiths said:

Unfortunately he came to me with a plantar 1st MTP joint ulcer.  

This ulcer could be new, recurrence/residual great toe infection, or nonhealing wound. Any x-ray? This will show osteomyelitic changes, air from communication with ulcer (showing that it's not healed and/or deep and/or associated with an abscess) and/or a foreign body. MRI preferred with and without contrast to r/o abscess. Monitor Cr. Can order CT W/WO if cannot order MRI. Agree with antibiotics but if this recurring or non-resolved osteomyelitis, pt will likely need IV antibiotics and possibly further surgical resection, especially if abscess formation. 

20 hours ago, mgriffiths said:

developed a draining lesion with streaking cellulitis lateral aspect of same lower extremity approximately 5cm inferior to knee.  From my experience I am extremely worried the patient's infection was never fully cleared and has now spread putting him at risk for BKA. Labs, imaging, and antibiotics started...but needless to say I'm frustrated.

The distance seems too large to think it communicates with the possible MTP infection. Diabetics, especially uncontrolled or fragile diabetics, can develop cellulitis from just looking at the skin. Add on top of that some sort of disruption in the skin barrier (scratch) and obesity, they're at a high risk for recurring cellulitis. I can't see the patient but I am more concerned that this is a separate infection and possible abscess. Does it appear to be just an ulcer? Also consider bilateral LE arterial duplex to eval for PAD, given his recurring infections and ulcers/nonhealing wounds; but these would be secondary to the infection workup.

Edited June 18, 2019 by Sed
Wording