Subjective

CC: Diabetic non-healing ulcerative right foot lesion.

HPT: EC is a 74 yo overweight man in moderate distress with dyspnea and difficulty walking. Patient has been treated by his PCP for 2 months for a non-healing ulcerative right foot lesion. The patient received azithromycin 250mg 5 day treatment for a purulent cough one week ago, which has not resolved. The patient’s wife believes the lesion was due to trauma, but the patient cannot identify when such an injury might have occurred. There is swelling and tenderness in his right leg and has a right ABI of 0.44 and left ABI of 0.78.

PMH: Right partial foot amputation, Dm, THN

SH: smoker 1PPD, 2PPDx 40 years, ready to quit. Denies ETOH and IVDA.

FH: non-contributory

Objective

Medications:

  • Insulin NPH-30 unit QAM and 10 unit QPM
  • Insulin R-10 units QAM
  • Timoptic 0.55 1gtt both eyes bid
  • Fluoxetine 60mg po QHS
  • Azithromycin 250mg po QD (3 doses)
  • Atropine 1% 1 gtt both eyes BID
  • ASA 325mg QD

NKDA

VS: 100.9F, BP 145/56 HR 69, RR 18, 200lbs, 6’0”

ROS

Non-contributatory except for R lateral foot discoid ulcerative wet lesion, “somewhat” infected with slight odor. Right calf circumference 3cm greater than left.

Laboratory

Culture has been taken of the ulcer. Initial staining indicates a variety of gram positive bacteria and minimal gram negative bacteria. Culture results are pending.

Assessment

Patient has a mixed infection diabetic foot ulcer. EC has two risk factors for MRSA, diabetes and gender. There are no signs of pus in the wound. Assuming the culture was taking according to IDSA guidelines, the wound has been debrided before culture collection. There is no indication in ROS that there was obvious bone involvement, but no X-Ray was ordered to confirm. This is a risk considering the patient’s history of amputation. According to IDSA guideline “Diagnosis and Treatment of Diabetic Foot Infections”, the patient has a mild diabetic foot infection. According to IDSA guidelines, Vancomycin is not indicated unless there is a proven or likely MRSA infection. Empiric therapy should consist of Dicloxacillin, clindamycin, Cephalexin, TMP/SMX or amoxicillin/clavulanate. Any antibiotic therapy should consider the patient’s pneumonia, preferably providing antibiotic coverage for both infections. Amoxicillin/clavulanate meets these requirments. The patient should be re-evaluated in 3 days for improvement. When wound cultures are complete, review therapy for appropriate coverage.

Blood glucose levels should be tightly controlled to improve healing time. Revascularization will also improve healing.

Plan

  • 2000 mg (2 tabs) ORALLY every 12 hr for 7-10 days (dose level for pneumonia, generally higher than recommended for soft tissue infections)
  • Re-evaluate in 3 days based on clinical signs and blood cultures
  • Adjust insulin therapy per diabetes plan