Concluded Case

A 65 years old lady presented with a case of non healing ulcer over right fore foot 2nd toe plantar aspect since 2 years and left foot for foot over since 3 years associated with history of foul smelling pis discharge and cellulitis and fever since 15days for this they came. BP 160/90 Lab routine TC 16000 DC (N) 84% HB 13 gm RBS 317mg/dl ABI bilateral 0.9 TBI bilateral 0.8 Provisional diagnosis Grade2 B Neurotrophic ulcer bilateral A/ w cellulitis and osteomyelitis ? Over 2nd phalanx right foot Type 2 Diabetes MELLITUS Hypertension Diabetic peripheral Neuropathy Discussion open my dear colleagues and respected seniors

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Uncontrolled DM with NHU both plantar aspect (DFUs), infected, poor wound management & offloading. Improper footwear & foot care. Start insulin basal-bolus regimen. Start injectable antibiotics especially Ertapenem 1gm OD IV along with LINEZOLID 600mg orally BID & Chymoral Forte BID/TID. Digital X-ray both feet to r/o any osteomyelitis changes & calcified blood vessels. Thoroughly debride the wound & the calosities. Daily dressing of wound with NS irrigation and Mupirocin Oint. Superoxide solution (Oxum) spray over the wound & dressing to keep the wound moist for better /faster healing. Offloading & elevation of lower limbs. After the healing of wound, do a foot mapping to know the kind of customised footwear or else can give a Diabetic footwear with punching out of the insoles on abnormal pressure areas. Patient should wear socks with footwear. Educate the patient about self care of foot with regular examination using mirror. I'm attaching pictures of ready-made diabetic footwears so as to have an idea.

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Peripheral vascular Ds. Peripheral neuropathy Diabetes mellitus

Aget Color Doppler
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Uncontrolled DM with NHU both plantar aspect (DFUs), infected, poor wound management & offloading. Improper footwear & foot care. Start insulin basal-bolus regimen. Start injectable antibiotics especially Ertapenem 1gm OD IV along with LINEZOLID 600mg orally BID & Chymoral Forte BID/TID. Digital X-ray both feet to r/o any osteomyelitis changes & calcified blood vessels. Thoroughly debride the wound & the calosities. Daily dressing of wound with NS irrigation and Mupirocin Oint. Superoxide solution (Oxum) spray over the wound & dressing to keep the wound moist for better /faster healing. Offloading & elevation of lower limbs. After the healing of wound, do a foot mapping to know the kind of customised footwear or else can give a Diabetic footwear with punching out of the insoles on abnormal pressure areas. Patient should wear socks with footwear. Educate the patient about self care of foot with regular examination using mirror. I'm attaching pictures of ready-made diabetic footwears so as to have an idea.

Thanks for you wonderful explanation sir
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Diabetic foot with neurotropic ulcer over plantar aspect of 2nd toe due to multiple factors. 1.Uncontrolled DM 2.Decreased blood flow due to diabetic peripheral vascular disease 3.Diabetic neuropathy 4.less vascular area . 5.May be associated osteomyelitis. Get a colour doppler study of lower limb vessels to look for PVD Treatment needed 1.Parenteral antibiotics- inj Piperacillin 4gm + tazobactum 500mg × 8 hourly for 5 days followed by oral antibiotics.prefererably Linezolid 600 mg B.D for 10 days considering osteomyelitis if any 2.Strict glycemic control with insulin. 3 Dressings with betadine lotion cleaning and mupirocin ointment. 4.Ensure protein, Zinc , vitamin C supplements 5.Tab cilostazol 100 mg B.D can increase the blood flow thereby promoting healing

Sir, Her ABI is absolutly normal and TBI also Normal
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Diabetes Mellitus, uncontrolled PERIPHERAL neuropathy, Osteomyelitis Chronic trophic ulcers with secondary infection Need to do arterial colour Doppler to check limb vascularity Otherwise routine management Rest, tight control of DM with insulin, debridement, dressings, antibiotics, metronidazole, Neurotropic vitamins Surgical opinion for osteomyelitis

Thank you doctor
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IT'S A..CASE OF.. * BILATERAL NEUROTROPHIC ULCERS.. WITH.. CELLULITIS AND ? OSTEOMYELITIS ..RT. 2ND PHALANX.. UNCONTROLLED DIABETES.. * NEED'S STRICT GLYCEMIC CONTROL WITH ANTIDIABETIC MANAGEMENT WITH EXPERTS OPINION.. * SURGEONS OPINION FOR WOUND MANAGEMENT.. * INVESTIGATIONS.. HBA1C.. COLOUR DOPLAR STUDY.. SWAB C AND S EXAMINATION.. X-RAY STUDY..

X ray will rule out ostemylitis Treat the DM ,Decide the necessity of insulin.I think insulin is absolute necessity for good healing. Daily dressing ,not to walk until the wound is get covered with scab . Antibiotics like clox is the need. Saline irrigation ,iodine wash or gauze dressing will promote faster healing. Good nutrition will help

Adv: HBA1c, venous colour Doppler T/t: prompt DM control First treat cellulitis with Iv antibiotics Chymoral fort Put on insulline PusC/s done Debridement done Regular dressing Proper follow up and monitoring Supportively B complex Vitamin c

Wash The Wound With Panchavalakala Decoction And Application Of Jatyaadi Ghrita Cteam Locally

Clean by trifala kashaay And jatyadi ghrta and dressing with shatdhaut ghrta

SUGGESTIVE OF DIABETIC FOOT WITH NEUROTROPIC ULCER

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