STATUS OF PATIENT :

A. PATIENT IDENTITY

Name Age Sex Occupation Religion Address Ethnic Date of admission Date of discharge

: Mrs. E : 50 years : Female : Housewife : Moslem : Kedaung : Javenese : February 11, 2012 : March 22, 2012

B. ANAMNESIS

Main complaint : Pain in the right foot

Additional complaints : - Numbness in the right leg - Difficulty to walk - Weakness - Nausea - Vommitus - Harder to breath - Bad appetite

History of present illness : Mrs. E , aged 50 years old has came to Arjawinangun hospital complained of pain in the right foot and numbness in the right leg, lower knee region. This complaints has been felt since a months ago and getting worst in this last 2weeks. Patient also said that on the right foot there is a large wound that swollen and suppurate and smells bad. Other than that patient also complained patients daily life activities were limited, as the patient had to use a

wheelchair to move because her difficulty to walk. She also feel harder to breath sometimes, weakness, nausea, and vomittus. Due to these the patient also had bad appetite.

Past medical history : Patient suffers from diabetes mellitus type 2 for the last 2 years, and was on treatment but not regulary take medicine. She also suffers from hypertension in this last year and never takes medications.

Family history of disease: There was no family history of this disease.

C. PHYSICAL EXAMINATION

General condition: Moderately ill appearance Consciousness: Compos mentis Vital sign : - Blood pressure: 120/80 mmHg - Pulse frequency: 80x/minute - Respiratory rate: 24x/minute - Temperature: 36.6 oC

General Status Skin Head : Skin color is black, no jaundice, enough turgor : Symmetrical, normochepal, equitable distribution of hair, no deformity. Eyes : Conjunctiva anemis (- / -), sclera icteric (- / -), isokor 3 mm pupil, light reflex (+ / +) normal Nose : Deviation of the septum (-), discharge (-)

Mouth : Lips are moist not dry and no cyanosis, tongue is not dirty Throat : Tonsil T1/T1, Pharynx not hypermic Ears Neck Thoracic : symmetrical, cerumen right-left (+)

: No deviated trahea, no palpable enlargement of lymph nodes. : Inspection Palpation : Symmetrical form and movement in right and left hemithorax : tactile fremitus symmetrical right and left

Percussion : sonor to the hemithorax

Auscultation: Pulmo: vesicular breath sound, Ronchi +/ +, wheezing - / Cor: heart sound I / II regular, Murmur (-), Gallop (-)

Abdomen : Inspection Palpation

: Symmetrical, flat abdomen, no visible abdominal mass : No abdominal tenderness, no muscular defense, no crepitus palpated, liver and spleen are not palpable, no abdominal mass.

Percussion : timpani in the entire quadrant of the abdomen. Auscultation : bowel sounds (+) Extremity: Warm acral, cyanosis - / -, edema - / -

Localist Status Pedal region Inspection : Seen large wound in right pedal sized 5x8 cm, the skin looks hyperemic, pus (+). Palpation : Pain (+), edema (+), the temperature is warmer than surrounding.

D. WORKUP Complete blood test March 20 2012: - Haemoglobin:8,8 g/dl - Haematocrit :27,2 % - Leukocytes :15.200 /ul - Thrombocyte :203.000 /ul

Blood glucose level March 20 2012: 241mg/dl

Kidney function March 20 2012: - Ureum - Creatinine - Uric acid : 53,3 mg/dl : 1,46 mg/dl : 2,24 mg/dl

E. WORKING DIAGNOSIS Diabetic foot ulcer

F. DIFFERENTIAL DIAGNOSIS - Arteriosclerosis obliteran - Chronic Venous Insufficiency

G. MANAGEMENT IVFD NaCl 20 drops/minutes PRC transfusion 500 cc Cefoperazone 2x 1amp Tramadol 2x1 amp Ranitidin 2x1 amp Debridement and Necrotomy Consult to Internist for Diabetes melitus type 2 management.

H. PROGNOSIS Quo ad vitam Quo ad functionam : dubia : dubia

DIABETIC ULCER
Foot ulcers are a significant complication of diabetes mellitus and often precede lower-extremity amputation. The most frequent underlying etiologies are neuropathy, trauma, deformity, high plantar pressures, and peripheral arterial disease. Sharp debridement and management of underlying infection and ischemia are also critical in the care of foot ulcers. Prompt and aggressive treatment of diabetic foot ulcers can often prevent exacerbation of the problem and eliminate the potential for amputation. The aim of therapy should be early intervention to allow prompt healing of the lesion and prevent recurrence once it is healed. Multidisciplinary management programs that focus on prevention, education, regular foot examinations, aggressive intervention, and optimal use of therapeutic footwear have demonstrated significant reductions in the incidence of lower-extremity amputations.

Examples of foot lesions. A, Necrobiosis lipoidica diabeticorum. B, Toe ulceration. C, Plantar ulcer beneath the head of the metatarsal bones. D, Combined ischemic and neuropathic ulceration; note dry blackish skin and dry gangrene of the little toe.

Gangrene Diabetic gangrene is commonly seen in diabetic patients as a complication. Gangrene is a condition that involves the death and decay of tissue, usually in the extremities. There are three different types of gangrene: dry, wet or gas gangrene. Dry gangrene is the one that most

often affects people with diabetes. Reduced blood flow or lack of circulation resulting from diabetes, cardiovascular problems, and smoking are the most common causes. Bacterial infections can also lead to gangrene. Toes, feet, lower limbs and sometimes fingers can all become vulnerable to the conditions that may cause gangrene. Symptoms include numbness in the affected part and it will also be cold to the touch.

Dry gangrene

At first, the area will become reddened but it gradually progresses to a brownish color. The skin may appear waxy. In the final stage, the affected body part will look withered and black in color. Gangrene is treatable if the symptoms are recognized early, before the death of tissue occurs. After tissue dies, removal of the dead tissue or amputation is the usual treatment

Charcot foot A Charcot foot is one characterized by destroyed bones and sometimes fractures and dislocations in the foot or ankle (Figure 3). Oftentimes, the arch of the foot collapses and there is a prominent bone felt on the bottom of the foot in the arch. This often leads to an ulcer on the bottom of the foot. Sometimes the bone will be infected if there is an ulcer that leads to it. Charcot foot is a condition that is commonly misdiagnosed as bone infection and may be unnecessarily amputated. It is important to have an expert in Charcot foot review the case prior to consenting to amputation because in the right hands, many cases are salvageable.

An X-ray f a Charcot foot that is dislocated A. CLASSIFICATION The Wagner and University of Texas systems are the ones most frequently used for classification of foot ulcers, and the stage is indicative of prognosis.

B. ETIOLOGY The etiology of diabetic foot ulcers usually has many components. A recent multicenter study attributed 63 percent of diabetic foot ulcers to the critical triad of peripheral sensory neuropathy, trauma, and deformity. Other factors in ulceration are ischemia, callus formation, and edema. Although infection is rarely implicated in the etiology of diabetic foot ulcers, the ulcers are susceptible to infection once the wound is present. Many of the risk factors for foot ulcer are also predisposing factors for amputation, because ulcers are primary causes leading to amputation. The etiologies of diabetic ulceration include neuropathy, arterial disease,]pressure, and foot deformity. Diabetic peripheral neuropathy, present in 60% of diabetic persons and 80%

of diabetic persons with foot ulcers, confers the greatest risk of foot ulceration; microvascular disease and suboptimal glycemic control contribute.

C. PATHOPHYSIOLOGY Atherosclerosis and peripheral neuropathy occur with increased frequency in persons with diabetes mellitus (DM). Diabetes related atherosclerosis Overall, people with diabetes mellitus (DM) have a higher incidence of atherosclerosis, thickening of capillary basement membranes, arteriolar hyalinosis, and endothelial proliferation. Calcification and thickening of the arterial media are also noted with higher frequency in the diabetic population, although whether these factors have any impact on the circulatory status is unclear. Significant atherosclerotic disease of the infrapopliteal segments is particularly common in the diabetic population. Underlying digital artery disease, when compounded by an infected ulcer in close proximity, may result in complete loss of digital collaterals and precipitate gangrene. Diabetic peripheral neuropathy

The pathophysiology of diabetic peripheral neuropathy is multifactorial and is thought to result from vascular disease occluding the vasa nervorum; endothelial dysfunction; deficiency of myoinositol-altering myelin synthesis and diminishing sodiumpotassium adenine triphosphatase (ATPase) activity; chronic hyperosmolarity, causing edema of nerve trunks; and effects of increased sorbitol and fructose. The result of loss of sensation in the foot is repetitive stress; unnoticed injuries and fractures; structural foot deformity, such as, metatarsal deformities, or Charcot foot. Unnoticed excessive heat or cold, pressure from a poorly fitting shoe, or damage from a blunt or sharp object inadvertently left in the shoe may cause blistering and ulceration. These factors, combined with poor arterial inflow, confer a high risk of limb loss on the patient with diabetes.

Charcot deformity with mal perforans ulcer of plantar midfoot.

D. EPIDEMIOLOGY Diabetic foot lesions are responsible for more hospitalizations than any other complication of diabetes. Among patients with diabetes, 15% develop a foot ulcer, and 1224% of individuals with a foot ulcer require amputation. In fact, every year approximately 5% of diabetics develop foot ulcers and 1% require amputation. Age Distribution Diabetes occurs in 3-6% of Americans. Of these, 10% have type 1 diabetes and are usually diagnosed when they are younger than 40 years. Diabetic neuropathy tends to occur about 10 years after the onset of diabetes, and, therefore, diabetic foot deformity and ulceration occur sometime thereafter. Prevalence by race The issue of diabetic foot disease is of particular concern in the Latino communities of the Eastern United States, in African Americans, and in Native Americans, who tend to have the highest prevalence of diabetes in the world. E. DIAGNOSIS The history should focus on symptoms indicative of possible peripheral neuropathy or peripheral arterial insufficiency.

 Symptoms Symptoms of peripheral neuropathy: - Hypesthesia - Hyperesthesia - Paresthesia - Dysesthesia - Radicular pain - Anhydrosis

Symptoms of peripheral arterial insufficiency Most people harboring atherosclerotic disease of the lower extremities are asymptomatic; others develop ischemic symptoms. Some patients attribute ambulatory difficulties to old age and are unaware of the existence of a potentially correctible problem. Patients who are symptomatic may present with intermittent claudication, ischemic pain at rest, nonhealing ulceration of the foot, or frank ischemia of the foot. Cramping or fatigue of major muscle groups in one or both lower extremities that is reproducible upon walking a specific distance suggests intermittent claudication. This symptom increases with ambulation until walking is no longer possible, and it is relieved by resting for several minutes. The onset of claudication may occur sooner with more rapid walking or walking uphill or up stairs. The claudication of infrainguinal occlusive disease typically involves the calf muscles. Discomfort, cramping, or weakness in the calves or feet is particularly common in the diabetic population because they tend to have tibioperoneal atherosclerotic occlusions. Rest pain is less common in the diabetic population. Physical Examination Physical examination Physical examination of the extremity having a diabetic ulcer can be divided into 3 broad categories:
-

Examination of the ulcer and the general condition of the extremity Assessment of the possibility of vascular insufficiency

Assessment for the possibility of peripheral neuropathy

Examination of extremity Diabetic ulcers tend to occur in the following areas: - Areas most subjected to weight bearing, such as the heel, plantar metatarsal head areas, the tips of the most prominent toes, and the tips of hammer. - Areas most subjected to stress, such as the dorsal portion of hammer toes

Other physical findings include the following: - Hypertrophic calluses - Brittle nails - Hammer toes - Fissures

Assessment of posible peripheral arterial insufficiency Physical examination discloses absent or diminished peripheral pulses below a certain level. Specifically, loss of the femoral pulse just below the inguinal ligament occurs with a proximal superficial femoral artery occlusion. Loss of the popliteal artery pulse suggests superficial femoral artery occlusion, typically in the adductor canal.Loss of pedal pulses is characteristic of disease of the distal popliteal artery or its trifurcation. Other findings suggestive of atherosclerotic disease include a bruit heard overlying the iliac or femoral arteries, skin atrophy, loss of pedal hair growth, cyanosis of the toes, ulceration or ischemic necrosis.

Assesment of posible periphral neuropathy Signs of peripheral neuropathy include loss of vibratory and position sense, loss of deep tendon reflexes (especially loss of the ankle jerk), trophic ulceration, foot drop, muscle atrophy, and excessive callous formation, especially overlying pressure points such as the heel. The nylon monofilament test helps diagnose the presence of sensory neuropathy.

F. DIFFERENTIAL DIAGNOSIS Atherosclerosis Chronic Venous Insufficiency Diabetic Foot Infections

G. WORKUP Patient workup for diabetic ulcers includes blood tests, ankle-brachial index, radiography, computed tomography, magnetic resonance imaging, and angiography. Blood Tests A complete blood count should be done. Leukocytosis may signal plantar abscess or other associated infection. Wound healing is impaired by anemia. In the face of underlying arterial insufficiency, anemia may precipitate rest pain. Assessment of serum glucose, glycohemoglobin, and creatinine levels helps to determine the adequacy of acute and chronic glycemic control and the status of renal function. Plain Radiography

Plain radiographic studies of the diabetic foot may demonstrate demineralization and Charcot joint and occasionally may suggest the presence of osteomyelitis.

Computed Tomography and Magnetic Resonance Imaging

Computed tomography (CT) scanning or magnetic resonance imaging (MRI) is indicated if a plantar abscess is suspected but not clear on physical examination. Conventional Angiography

If vascular or endovascular surgical treatment is contemplated, angiography is needed to delineate the extent and significance of atherosclerotic disease.

H. MANAGEMENT The management of diabetic foot ulcers requires offloading the wound by using appropriate therapeutic footwear, daily saline or similar dressings to provide a moist wound environment, debridement when necessary, antibiotic therapy if osteomyelitis or cellulitis is present, optimal control of blood glucose, and evaluation and correction of peripheral arterial insufficiency.

Wound and Foot Care The basic principle of topical wound management is to provide a moist, but not wet, wound bed.

Wound coverage After debridement, apply a moist sodium chloride dressing or isotonic sodium chloride gel or a hydroactive paste. Optimal wound coverage requires wet-to-damp dressings, which support autolytic debridement, absorb exudate, and protect surrounding healthy skin. A polyvinyl film dressing that is semipermeable to oxygen and moisture and impermeable to bacteria is a good choice for wounds that are neither very dry nor highly exudative. Wound coverage recommendations for some other wound conditions are as follows:
-

Dry wounds: Hydrocolloid dressings Exudative wounds: Absorptive dressings, such as calcium alginates Very exudative wounds: Impregnated gauze dressings or hydrofiber dressings Infected wounds: For infected superficial wounds, use Silvadene Wounds covered by dry eschar: Simply protecting the wound until the eschar dries and separates may be the best management. Painting the eschar with povidone iodine is beneficial.

Fragile periwound skin: Hydrogel sheets and nonadhesive forms.

Other topical preparations that occasionally may be useful in the management of diabetic foot ulcers are as follows:
-

Platelet-derived growth factors (PDGF): Topical recombinant human PDGF has a beneficial effect in promoting wound healing.

Collagen debridement

Treatment of Charcot foot Charcot foot is treated initially with immobilization using special shoes or braces but eventually may require podiatric surgery such as ostectomy and arthrodesis. Surgical care Surgeon will consider debridement, revisional surgery on bony architecture, vascular reconstruction, and options for soft tissue coverage

 Debridement Surgical management is indicated for debridement of nonviable and infected tissue from the ulceration, removal of excess callus, curettage of underlying osteomyelitic bone, skin grafting, and revascularization. The wound usually requires an initial surgical debridement and probing to determine the depth and involvement of bone or joint structures. Visible or palpable bone implies an 85% chance of osteomyelitis. Revisional surgery Such intervention includes resection of metatarsal heads or ostectomy may be required to remove pressure points. Vascular reconstruction Indications for vascular surgery of a reconstructible arterial lesion include continous pain at rest or at night, foot ulcers that difficult to heal, and impending or existing gangrene.

I.

PREVENTION

Daily foot inspection Gentle soap and water cleansing Application of skin moisturizer Inspection of the shoes to ensure good support, fit, and comfort. Minor wounds require prompt medical evaluation and treatment. Prophylactic podiatric surgery to correct high-risk foot deformities may be indicated. Avoid hot soaks, heating pads, and irritating topical agents.

REFERENCE

Sjamsuhidajat R., Wim de Jong. Buku ajar Ilmu Bedah, Edisi II. Jakarta : EGC, 2004.

Rowe Lopez. Diabetic Ulcer. on http://emedicine.medscape.com/article/460282overview#showall Michael Stuart Bronze, MD. Diabetic Foot Infections. on

http://emedicine.medscape.com/article/237378-overview Robert G. Frykberg, D.P.M.,M.P.H. Diabetic Foot Ulcers: Pathogenesis and Management. On http://www.aafp.org/afp/2002/1101/p1655.html Rooh-Ul-Muqim, Samson Griffin, Mukhtar Ahmed. Evaluation and Management of Diabetic Foot According to Wagners Classification a Study of 100 Cases. On http://www.ayubmed.edu.pk/JAMC/PAST/15-3/rooh.htm Grace A. Pierce, Borley R. Neil. At a Glance Ilmu Bedah Edisi III. Jakarta : Erlangga. 2006 Ingrid Kruse, DPM,Steven Edelman, MD. Evaluation and Treatment of Diabetic Foot Ulcers. On http://clinical.diabetesjournals.org/content/24/2/91.full