Clinical Case 047: Not so sweet feet

This week a classic Australian remote area case.  There is so much to discuss on this case!  But I have isolated a few key points to put under the microscope, and get your input / expertise.

47 yo. Aboriginal woman has returned to the ED complaining of painless purulent lesions on her left foot.  She was seen a week ago by the nice city locum who diagnosed cellulitis and commenced her on a week of oral flucloxacillin.  She has been taking this for 6 days, but it aint working!

Not so good.  She reports increasing ooze, and the occasional maggot escaping from her improvised dressing.

Here is the background info:

PMHx:  Diabetic (type 2 – is there any other kind?)

  • Hypertensive
  • Nephropathy with significant proteinuria, Cr 100 last visit
  • Retinopathy requiring laser last year
  • No documented ischemic heart disease, CVA or PVD

Meds:  metformin 2 g/day SR, Gliclazide 120 mg MR,  Quinapril 20 mg, aspirin 150 mg/d.  No Allergies

She is overweight with a BMI of 39.  Central adiposity.  Malodourous slough coming off the foot.  She has a good dorsalis pedis and posterior tibial pulse to feel

Obs: T = 38.4,  pulse = 98 SR, BP = 166/102,  RR 14, Sats 97% RA.  Her BSL is 29 mmol (~ 520 in USA)

This is bread and butter for the remote area docs, so i am going to ask 3 questions for you to ponder and comment upon…

Q1:  Antibiotics in this scenario – what are you going to use? Any particular pathogens to keep in mind?

Q2:  Imaging – what do you do?  Are plain films worthwhile?

Q3:  Management of her hyperglycemia (assume she is admitted) – what targets and what to use to achieve this?

….. OK, bonus question… #4 :  Maggots…. good, bad or indifferent?

Get your thinking caps on.  Especially you Dr Dorr – I am gonna quiz you on this this week!

Casey

 

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