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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Recognize the signs and symptoms of diabetic foot infections and identify the risk factors and the most likely pathogens associated with these infections.

  • Recommend appropriate antimicrobial regimens for diabetic foot infections, including for patients with drug allergies or renal insufficiency.

  • Recommend appropriate home IV therapy and proper counseling to patients.

  • Outline monitoring parameters for achievement of the desired pharmacotherapeutic outcomes and prevention of adverse effects.

  • Counsel diabetic patients about adequate blood glucose control as part of an overall plan for good foot health.

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PATIENT PRESENTATION

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Chief Complaint

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As per the Spanish interpreter: “He had an ingrown toe nail that became infected several weeks ago, and now the whole foot is swollen.”

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HPI

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Jesus Chavez is a 67-year-old Hispanic man, Spanish-speaking only, who presents to the ED complaining of a sore and swollen foot. Three weeks ago he noticed that his right great toe became swollen and red due to an ingrown toenail. The patient tried to fix the nail with scissors and tweezers, but the swelling got worse, and thick, foul-smelling drainage became noticeable approximately 2 weeks ago. The patient was visiting family in Mexico at the time and now has just returned home to New Mexico. History is per translation by a hospital interpreter. The patient is accompanied by his wife who also only speaks Spanish.

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Primary care physician is Dr Martinez at First Choice Clinic in Albuquerque.

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PMH

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  • Type 2 DM × 18 years

  • Hospitalized 2 months ago for HHS

  • Left second toe amputation 1 year ago secondary to diabetic foot infection

  • Hyperlipidemia

  • Hypertension

  • Chronic renal insufficiency

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FH

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  • Father is deceased (56-year-old) secondary to MI, type 2 DM, HTN

  • Mother is deceased secondary to breast cancer (41-year-old)

  • One daughter, alive and well, 42-year-old

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SH

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The patient lives with his wife in Albuquerque, New Mexico. He denies tobacco and illicit drug use; however, he admits to a long history of drinking four to five beers per day. He admits to nonadherence with his medications and glucometer.

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Meds

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  • Lantus SoloStar 40 units once daily

  • Humalog KwikPen 12 units with each meal

  • Metformin 1,000 mg PO twice daily

  • Aspirin 81 mg PO once daily

  • Lisinopril 20 mg PO once daily

  • Atorvastatin 40 mg PO daily

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All

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Sulfa—severe rash.

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ROS

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Negative except as noted in the HPI

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Physical Examination

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Gen
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Patient is a thin Hispanic man who appears very concerned about losing his foot.

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VS
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BP 126/79, P ...

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