REASON FOR CONSULTATION: Left diabetic foot infection. Please evaluate for antibiotics and treatment plan.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male with past medical history significant for diabetes mellitus type 2, who was directly admitted to the hospital from the primary care’s office secondary to concern of a complicated left diabetic foot infection. The patient gives a history that he had not seen a physician for a number of years regarding his diabetes. He had peripheral neuropathy, and a few weeks earlier, he had developed ulceration on both his toes, right as well as the left big toe, on the plantar aspect of the right as well as the left big toe. He had not sought medical care and had continued to work. He started to have fevers and chills with increasing erythema of his left foot, of his left big toe, and he decided to come to the emergency room for evaluation here. The patient was evaluated and placed on oral antibiotics per the patient and discharged to outpatient followup. The next day, he showed up at his primary care’s office where he was evaluated. He was noted to have a black left toe and was directly admitted to the hospital and I am asked to evaluate the patient.
REVIEW OF SYSTEMS: He gives history of fevers and chills. Denies any cough, production of sputum, pleuritic chest pain, orthopnea, PND or dyspnea on exertion. Denies headache or syncope. Denies nausea, vomiting, abdominal cramps or diarrhea. Denies any urinary complaints. Denies any joint complaints. Does give history of chronic ulceration of both his big toes. Gives history of chronic ulceration of big toes, both feet.
PAST MEDICAL HISTORY: Significant for diabetes mellitus type 2 with peripheral neuropathy.
ALLERGIES: No known antibiotic allergies.
SOCIAL HISTORY: He is a smoker of about 12 years, smoking about less than a pack a day. There is no alcohol use or intravenous drug use. He lives locally.
FAMILY HISTORY: Unremarkable.
OUTPATIENT MEDICATIONS: The patient was only taking enteric-coated aspirin daily.
GENERAL: On examination, the patient is comfortable, in no acute distress. He is awake, alert, oriented, and pleasant. He is noted to be afebrile. Heart rate is 104 and blood pressure is 136/78. He is 98% on room air.
HEENT: Pupils are equal and reactive to light and accommodation. Sclerae are anicteric. Oral mucosa is moist without any exudate. The patient is noted to have severe gingivitis and dental caries.
LUNGS: Clear to auscultation. No wheezes and crackles are noted.
HEART: S1 and S2. He is tachycardic. Regular rate and rhythm. No murmurs are noted.
ABDOMEN: Soft, nontender, and nondistended. Gut sounds are present. No organomegaly is palpable.
EXTREMITIES: Evaluation of his extremities shows good arterial pulses. No evidence of edema is noted. Evaluation of his left foot shows gangrene of his left big toe with increasing erythema extending onto the dorsum of the foot. Evaluation of his right foot shows grade 2 to 3 Wagner’s ulcer, right hallux.
SKIN: Without rash. IV sites appear clean.
LABORATORY DATA: The patient had a chest x-ray performed on admission, which did not show any evidence of consolidation. In addition, x-rays of his left foot showed fracture and lucencies possible with osteolysis, distal phalanx of great toe, with soft tissue defects, superimposed osteomyelitis. Subcutaneous emphysema was also noted raising the possibility of an infection. The patient had blood cultures done on (XX) in addition to (XX), which remained negative to date. No other culture data is available. CBC shows a white cell count of 12.10 down from 25,000 on (XX). Hemoglobin and hematocrit of 11.8 and 35.2 and platelets are 465. Differential is not performed. Chemistry profile shows creatinine of 0.8. Serum electrolytes are within normal limits. Liver function test also appeared to be within normal limits.
ASSESSMENT: This is a (XX)-year-old male with past medical history significant for diabetes mellitus type 2 and peripheral neuropathy, who comes to the emergency room, who is directly admitted to the hospital for workup of a complicated diabetic foot infection, left foot. The patient has evidence of gangrene of his left big toe. Podiatry consultation has been placed and the patient will require amputation of his left big toe. He has good arterial pulses; however, he is noted to have a peripheral neuropathy. Therefore, we would recommend that the patient will be started on broad spectrum antibiotic coverage, that is Zosyn, in addition to vancomycin until workup and culture data are more mature.
In addition, the patient is noted to have grade 2 to 3 Wagner’s ulcer on the plantar aspect of his right big toe requiring debridement. This will also be discussed with podiatry.
SUGGESTIONS:
- Zosyn 3.35 g IV every 6 hours.
- Vancomycin per pharmacy protocol, target trough 11 and 15.
- ESR and CRP.
- Podiatry consultation and evaluation is pending.
- The patient needs to quit smoking.
- Dental care was addressed with the patient.
- The patient should have a nasal swab for MRSA.
- HIV screen is also recommended.
Thank you for this consultation. We will be following the patient with you.
