#june2020amc1
A 52-year-old insulin-dependant diabetic patient presents following a trivial injury to the mid-foot whilst gardening. 24 hours later his foot is very warm and swollen. He has been bearing weight normally. Inflammatory markers are normal. His HbA1c is 80. On examination, the foot is warm to touch, with a temperature difference of 2.5oC. He has a dense peripheral neuropathy. There is no evidence of an infective collection. Radiographs were normal apart from some calcification of the dorsal pedis artery. His pulses were palpable. Which one of the following is the next most appropriate course of action?
A. Admit for intravenous antibiotics for cellulitis, keeping the patient as mobile as he is able.
B. Advise incision and drainage of a possible diabetic abcess.
C. Apply a total contact plaster cast, non-weight bearing.
D. Discharge home with advice to rest and elevate the limb and seek advice if the symptoms do not improve. Crutches if required.
E. Issue the patient with crutches and review the patient in the ED trauma clinic 2 weeks thereafter.
Explanatory Notes:
In diabetic patients with peripheral neuropathy, a warm swollen foot may be indicative of a Charcot process. Pulses are often normal.
This is not an infective process, though this should be part of your differential.
The patient requires immobilisation in a total contact cast. Failure to protect and immobilise the limb may result in gross architectural deformity of the foot. Review at the joint diabetic foot clinic, where the patient will be seen by a diabetologist, a vascular surgeon and an orthopaedic surgeon is mandated.
A 52-year-old insulin-dependant diabetic patient presents following a trivial injury to the mid-foot whilst gardening. 24 hours later his foot is very warm and swollen. He has been bearing weight normally. Inflammatory markers are normal. His HbA1c is 80. On examination, the foot is warm to touch, with a temperature difference of 2.5oC. He has a dense peripheral neuropathy. There is no evidence of an infective collection. Radiographs were normal apart from some calcification of the dorsal pedis artery. His pulses were palpable. Which one of the following is the next most appropriate course of action?
A. Admit for intravenous antibiotics for cellulitis, keeping the patient as mobile as he is able.
B. Advise incision and drainage of a possible diabetic abcess.
C. Apply a total contact plaster cast, non-weight bearing.
D. Discharge home with advice to rest and elevate the limb and seek advice if the symptoms do not improve. Crutches if required.
E. Issue the patient with crutches and review the patient in the ED trauma clinic 2 weeks thereafter.
Explanatory Notes:
In diabetic patients with peripheral neuropathy, a warm swollen foot may be indicative of a Charcot process. Pulses are often normal.
This is not an infective process, though this should be part of your differential.
The patient requires immobilisation in a total contact cast. Failure to protect and immobilise the limb may result in gross architectural deformity of the foot. Review at the joint diabetic foot clinic, where the patient will be seen by a diabetologist, a vascular surgeon and an orthopaedic surgeon is mandated.
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