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CASE MANAGEMENT DISCUSSION- PRESENTATION AND SHARING OF INFORMATION ON COMPLICATED SKIN AND SOFT TISSUE INFECTION Rommel Q. de Leon, MD Department of Surgery.

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Presentation on theme: "CASE MANAGEMENT DISCUSSION- PRESENTATION AND SHARING OF INFORMATION ON COMPLICATED SKIN AND SOFT TISSUE INFECTION Rommel Q. de Leon, MD Department of Surgery."— Presentation transcript:

1 CASE MANAGEMENT DISCUSSION- PRESENTATION AND SHARING OF INFORMATION ON COMPLICATED SKIN AND SOFT TISSUE INFECTION Rommel Q. de Leon, MD Department of Surgery Ospital ng Maynila Medical Center

2 GENERAL DATA D. F. 58/M From Intramuros, Manila

3 CHIEF COMPLAINT NON-HEALING WOUND, FOOT, RIGHT

4 HISTORY OF PRESENT ILLNESS 2 weeks PTA Patient noted crusting lesions over the dorsum and interdigital areas of the right foot noted to be non- healing accompanied by pruritus No medications taken No consult done

5 HISTORY OF PRESENT ILLNESS 1 week PTA Spread of the lesions to other parts of the foot Lesions with foul- smelling discharge Swelling and erythema No medications taken No consult done

6 HISTORY OF PRESENT ILLNESS Few hrs PTA Increased severity of swelling Increased spread of lesions Consult

7 PAST MEDICAL HISTORY (+) Diabetes Mellitus Type II x 20 yrs- Regular and Intermediate Insulin - Regular Insulin 5 u SQ for CBG > 250 mg/dl - Intermediate insulin 16 u in AM 8 u in PM NON-COMPLIANT S/P BKA, Left- 2004, OMMC PTB Minimal- 2004, OMMC Rx: anti-Kochs, non- compliant

8 FAMILY HISTORY (+) Diabetes Mellitus Type II- both parents

9 PERSONAL AND SOCIAL HISTORY Smoker, 20 pack years Alcoholic Beverage Drinker 4x a week

10 PHYSICAL EXAMINATION GENERAL SURVEY: conscious, coherent, NICRD BP= 120/ 80 CR= 78RR= 22T= 37º HEENT: pink palpebral conjunctiva, anicteric sclera, no TPC, no CLAD CHEST / LUNGS: SCE, no retractions, clear breath sounds HEART: adynamic precordium, NRRR, no murmur

11 PHYSICAL EXAMINATION ABDOMEN: flat, NABS, soft, non-tender

12 PHYSICAL EXAMINATION (lower extremities)

13 PHYSICAL EXAMINATION

14 PHYSICAL EXAMINATION (lower extremities) BKA scar, Left foot DERMATOLOGIC: (+) swollen erythematous right foot; (+) multiple crusting weeping lesions over the dorsum of the forefoot and on the interdigital areas, R; (+) ulcerating wound with multiple crusting weeping lesions, dorsum and sole foot, R VASCULAR: (+) pitting edema above the ankle; diminished dorsalis pedis pulses; strong posterior tibial, popliteal and femoral pulses; poor capillary filling time (> 3 sec); (-) temperature gradient

15 PHYSICAL EXAMINATION (lower extremities) NEUROLOGIC: Poor light touch perception; poor pinprick sensation; poor two-point discrimination; poor temperature discrimination

16 SALIENT FEATURES 1.58/M 2.2 wks history non-healing wound right foot with pruritic crusting lesions accompanied by erythema and swelling that spread to other parts of the foot with foul-smelling discharge 3.(+) DM Type II x 20 yrs, non-compliant to medications 4.(+) History of previous amputation for diabetic gangrene of the left foot (2004-OMMC) 5.(+) DM Type II both parents

17 SALIENT FEATURES 6. PE of the Right foot: DERMATOLOGIC: (+) swollen erythematous right foot; (+) multiple crusting weeping lesions over the dorsum of the forefoot and on the interdigital areas, R; (+) ulcerating wound with multiple crusting weeping lesions, dorsum and sole foot, R VASCULAR: (+) pitting edema above the ankle; diminished dorsalis pedis pulses; strong posterior tibial, popliteal and femoral pulses; poor capillary filling time (> 3 sec); (-) temperature gradient NEUROLOGIC: Poor light touch perception; poor pinprick sensation; poor two-point discrimination; poor temperature discrimination

18 DM TYPE II PATIENT NON-HEALING WOUND ON THE FOOT POOR DM CONTROL SUPERFICIALDEEP SIGNS AND SYMPTOMS OF INFECTION

19 DM TYPE II PATIENT NON-HEALING WOUND ON THE FOOT POOR DM CONTROL SUPERFICIALDEEP SIGNS AND SYMPTOMS OF INFECTION -FUNGAL INFECTION WITH SUPERIMPOSED BACTERIAL INFECTION - SWELLING AND INDURATION - DERMATOLOGIC PRESENTATION - ERYTHEMA AND EDEMA ABOVE THE ANKLE - WOUND BREAKDOWN - ULCERATION / UNDERMINING - VASCULAR CHANGES - DIMINISHED SENSORY PERCEPTION

20 CLINICAL DIAGNOSIS DEGREE OF CERTAINTY MANAGEMENT DEEP SOFT TISSUE INFECTION PROBABLY 2º TO DIABETIC FOOT, RIGHT DM TYPE II POORLY CONTROLLED S/P BKA, L 90%SURGICAL SUPERFICIAL SOFT TISSUE INFECTION PROBABLY 2º TO FUNGAL INFECTION WITH SUPERIMPOSED BACTERIAL INFECTION DM TYPE II POORLY CONTROLLED S/P BKA, L 10%MEDICAL

21 PARACLINICAL DIAGNOSTIC PROCEDURE DO I NEED A PARACLINICAL DIAGNOSTIC PROCEDURE? YES. - TO INCREASE THE DEGREE OF CERTAINTY OF MY PRIMARY CLINICAL DIAGNOSIS - THEY HAVE DIFFERENT TREATMENT MODALITIES

22 GOALS OF PARACLINICAL DIAGNOSTIC PROCEDURE DETERMINE THE DEPTH OF INFECTION

23 PARACLINICAL DIAGNOSTIC PROCEDURES DIAGNOSTIC PROCEDURE BENEFITRISKCOSTAVAILABILITY PLAIN RADIOGRAPHS ++RADIATION EXPOSURE Php CT SCAN+++RADIATION EXPOSURE Php TECHNETIUM BONE SCANS ++ LESS SPECIFICITY RADIATION EXPOSURE Php WHITE BLOOD CELL SCINTIGRAPHY +++ HIGHLY SPECIFIC AND SENSITIVE NA MRI+++NAPhp

24 XRAY RESULTS: - OSTEOPOROTIC OSSEOUS STRUCTURE WITH SOME OSTEOLYTIC CHANGES ON THE DISTAL DIGITS -SOFT TISSUE ABSCESSES NOTED ON ALL DIGITS

25 PRE-TREATMENT DIAGNOSIS DIABETIC FOOT, RIGHT DIABETES MELLITUS TYPE II POORLY CONTROLLED S/P BKA, LEFT

26 GOALS OF TREATMENT 1.REMOVAL OF NECROTIC TISSUE 2.CONTROL OF THE INFECTION 3.RESTORATION OF VASCULAR PERFUSION 4.MEDICAL MANAGEMENT OF HYPERGLYCEMIA

27 TREATMENT OPTIONS – GOALS 1 TO 3 TREATMENT OPTIONS BENEFITRISKCOSTAVAILABILITY DEBRIDEMENT*++ FAILURE RATE= 71% RISK OF OPERATION Php SYMES / FOREFOOT AMPUTATION* ++ FAILURE RATE= 49% RISK OF OPERATION Php MAJOR AMPUTATION (BELOW THE KNEE)* +++ SUCCESS RATE= 92-99% RISK OF OPERATION Php * ALL PROCEDURES REQUIRE ADEQUATE ANTIBIOTIC COVERAGE

28 TREATMENT OPTIONS – GOAL 4 TREATMENT OPTIONS BENEFITRISKCOSTAVAILABILITY ORAL ANTIHYPER- GLYCEMIC AGENTS ++HypoglycemiaPhp 2000/wk +++ INSULIN+++ (Indicated in patients with ongoing infection) HypoglycemiaPhp 3000/wk +++

29 TREATMENT PLAN (SURGICAL) BELOW THE KNEE AMPUTATION, RIGHT

30 TREATMENT PLAN (MEDICAL) INSULIN (SHORT AND LONG ACTING) FOR CONTROL OF HYPERGLYCEMIA

31 PRE-OP PREPARATION PSYCHOSOCIAL SUPPORT SCREENING FOR MEDICAL PROBLEMS DM TYPE II- CBC, CBG MONITORING, FBS, BUN, CREATININE, SERUM K, URINALYSIS, LIPID PROFILE, HgbA1C CHEST X-RAY – PTB MINIMAL ECG- NON-SPECIFIC ST-T WAVE CHANGES

32 PRE-OP PREPARATION OPTIMIZE PHYSICAL CONDITION OF THE PATIENT FLUID RESUSCITATION ADEQUATE ANTIBIOTIC COVERAGE CONTROL OF HYPERGLYCEMIA (Co-Management with IM) CBG monitoring AC/HS Regular Insulin 5 units SQ for CBG > 250 mg/dl Intermediate Insulin 16 units SQ in AM, 8 units SQ in PM

33 SURGICAL TREATMENT (Intra-op) Tourniquet Level of bony resection marked and AP diameter measured Anterior and posterior flaps (1/2 AP diameter) marked

34 SURGICAL TREATMENT (Intra-op) Skin, subcutaneous fat and fascia divided in the same line as with the periosteum of the antero-medial surface of the tibia Flaps elevated to the level of the amputation

35 INTRAOPERATIVE FINDINGS Gangrenous material noted with foul- smelling purulent discharge Good pulses and good muscle viability with brisk bleeding noted at the level of amputation

36 SURGICAL TREATMENT (Intra-op) Superficial peroneal nerve identified, pulled distally and divided Anterior tibial vessels and deep peroneal nerve divided Anterior muscles sectioned 0.75 cm distal the bony resection

37 SURGICAL TREATMENT (Intra-op) Tibia bevelled at level of resection prior to division of the bone Fibula sectioned 3 cm proximal to tibia

38 SURGICAL TREATMENT (Intra-op) Posterior vessels and nerve divided Posterior flap and aponeurosis of gastrocnemius fashioned to meet anterior muscles Tourniquet released and obtained haemostasis

39 SURGICAL TREATMENT (Intra-op) Wound closed in layers (fascia, fat and skin) and apply a stump bandage

40 OPERATION DONE BELOW THE KNEE AMPUTATION, RIGHT

41 FINAL DIAGNOSIS DIABETIC FOOT, RIGHT DIABETES MELLITUS TYPE II POORLY CONTROLLED S/P BKA, LEFT

42 POST-OPERATIVE CARE SUPPLY THE BASIC NEEDS OF THE PATIENT COMFORT ANALGESICS CBG MONITORING AND CONTROL OF HYPERGLYCEMIA MEDICATIONS – ANTIBIOTICS FLUIDS AND ELECTROLYTES REHABILITATION / POSSIBLE PROSTHESIS

43 POST-OPERATIVE CARE SUPPORT ORGAN FUNCTION WOUND CARE MONITORING FOR COMPLICATIONS ADVICE ON HOME CARE FOLLOW-UP PLAN

44 POST-OPERATIVE CARE PATIENT DISCHARGED ON 3 RD POD: 1. LIVE 2. WITH NO COMPLICATION 3. SATISFIED 4. WITH NO MEDICO-LEGAL SUIT

45 FOLLOW-UP PLAN REMOVAL OF SUTURES AFTER DAYS ADVICE ON WOUND CARE ORAL ANTIBIOTICS FOR 5-7 DAYS CONTINUATION OF CBG MONITORING CONTROL OF HYPERGLYCEMIA WITH CO- MANAGEMENT WITH INTERNAL MEDICINE ADVICE FOR PROSTHESES AND REHABILITATION

46 SHARING OF INFORMATION DIABETIC FOOT

47 DEFINITION Infection, ulceration and/or destruction of deep tissues associated with neurological abnormalities and various degrees of peripheral vascular disease in the lower limb (WHO, 1985) The term diabetic foot indicates that there are specific qualities about the feet of people with diabetes that sets this disease apart from other conditions that affect the lower extremity (Habershaw & Chzran, 1995)

48 DEFINITION …the many different lesions of the skin, nails, bone and connective tissue in the foot which occur more often in diabetic patients than non- diabetic patients such as ulcers, neuropathic fractures, infections, gangrene and amputations(De Heus-van Putten, 1994) The term diabetic foot implies that the pathophysiological processes of diabetes mellitus does something to the foot that puts it at increased risk for tissue damage. (Payne & Florkowski, 1998)

49 GENERALITIES THREE BROAD TYPES OF DIABETIC FOOT ULCERS: neuropathic ischaemic neuroischaemic

50 Diabetic foot ulcers are classified using the commonly used Wagners Classification GradingFeatures 0Pre-ulcer. No open lesion. May have deformities, erythematous areas of pressure or hyperkeratosis. 1Superficial ulcer. Disruption of skin without penetration of subcutaneous fat layer. 2Full thickness ulcer. Penetrates through fat to tendon or joint capsule without deep abscess or osteomyelitis. 3Deep ulcer with abscess, osteomyelitis or joint sepsis. It includes deep plantar space infections, abscesses, necrotizing fascitis and tendon sheath infections. 4Gangrene of a geographical portion of the foot such as toes, forefoot or heel. 5Gangrene or necrosis of large portion of the foot requiring major limb amputation.

51 Depth-Ischemia Classification of Diabetic Foot Lesions DEPTH CLASSIFICATION DEFINITIONTREATMENT 0At-risk foot, no ulcerationPatient education, accommodative footwear, regular clinical examination 1Superficial ulceration, not infected Offloading with total contact cast (TCC), walking brace or special footwear 2Deep ulceration exposing tendons or joints Surgical debridement, wound care, offloading, culture-specific antibiotics 3Extensive ulceration or abscess Debridement or partial amputation, offloading, culture-specific antibiotics *Adapted from Brodsky, J: The Diabetic Foot. In Surgery of the Foot and Ankle, Coughlin, MJ, and Mann, RA, editors. Mosby Inc., St. Louis, Table 21-2, page 911.

52 Depth-Ischemia Classification of Diabetic Foot Lesions ISCHEMIA CLASSIFICATION DEFINITIONTREATMENT ANot ischemic BIschemia without gangrene Noninvasive vascular testing, vascular consultation if symptomatic C Partial (forefoot) gangrene Vascular consultation D Complete foot gangrene Major extremity amputation, vascular consultation

53 GENERALITIES ANATOMICAL DISTRIBUTION : 1.~50% of ulcers are on the toes 2. ~30-40% are on the plantar metatarsal head 3.~10-15% are on the dorsum of the foot 4. ~5-10% are on the ankle 5.up to 10% are multiple ulcers

54 Mechanisms Of Injury That Destroy The Foot 1) Direct mechanical disruption of tissue (eg patient stepping on nail while barefoot abruptly breaking the skin barrier) 2) Small amount of force that is sustained over time that leads to ischaemia (eg tight shoe may lead to breakdown of union site) 3) Moderate amount of force that is repeated over and over leads to inflammation and enzymatic autolysis of tissue (eg plantar metatarsal ulceration) 4) Infection

55 PRECIPITATING EVENTS THAT INCREASE RISK FOR TISSUE DAMAGE 1.Accidental cuts 2.Shoe trauma 3.Repetitive stress 4.Thermal trauma 5.Iatrogenic 6.Vascular occlusion 7.Skin or nail conditions

56 DEMOGRAPHIC RISK FACTORS -Age (older at greater risk) -Gender (male is at 2x greater) -Ethnicity (some ethnic groups are at signifcantly increased risk for foot complications) - Social situation (living alone 2x greater risk)

57 DIABETES RELATED RISK FACTORS Duration of diabetes Glycaemic control Loss of protective sensation - main risk factor; permissive of unperceived injury Motor neuropathy (muscle wasting and gait changes; the intrinsic minus foot – high arched, claw toes, intrinsic muscle wasting) Autonomic neuropathy - microvascular dysfunction; Anhidrotic, dry, cracked skin

58 DIABETES RELATED RISK FACTORS Peripheral vascular disease (4x more common in those with diabetes) Increased plantar pressures Limited joint mobility (AGEs/glycation of collagen; restricts movement of key joints; related to increased plantar pressures)

59 DIABETES RELATED RISK FACTORS Immune/Defence mechanisms (infections are more common; the immune responses are impaired due to vascular supply factors, chemotatic factors and a reduced neutrophil response) Previous ulceration (this is THE main risk factor for ulceration )

60 OTHER RISK FACTORS Body weight (higher prevalance in those with type 2 diabetes) Smoking Footwear

61 HISTORY GENERAL FOOT-SPECIFIC WOUND / ULCER HISTORY

62 PHYSICAL EXAMINATION 1.MUSCULOSKELETAL 2.DERMATOLOGIC 3.VASCULAR 4.NEUROLOGIC 5.FOOTWEAR

63 Musculoskeletal Examination Attitude and posture of lower extremities and foot Orthopedic deformities – Hammertoes / Bunions / Pes planus or cavus / Charcot deformities / amputations / prominent metatarsal heads Limited joint mobility Tendo - Achilles contractures / equinus Gait evaluation Muscle group strength testing Plantar pressure assessment

64 Dermatological Examination Skin appearance: color, texture, turgor, quality, and dry skin Calluses or heel fissures Nail appearance: Onychomycosis, dystrophic, atrophy, hypertrophy, paronychia Presence of hair Ulceration, gangrene, infection Interdigital lesions Tinea pedis

65 Vascular Examination Pulses (dorsalis pedis, posterior tibial, popliteal, femoral) Capillary return (normal < 3 seconds) Venous filling time (normal < 20 seconds) Presence of edema Temperature gradient Colour changes: Cyanosis, dependent rubor, erythema Changes of ischemia: Skin atrophy; nail atrophy, abnormal wrinkling, diminished pedal hair

66 Neurological Examination Vibration perception: Tuning fork 128cps Light pressure: cotton wool Pain: Pinprick Two-point discrimination Temperature perception: hot and cold

67 Neurological Examination Deep tendon reflexes: ankle, knee Clonus testing Babinski test Romberg's test

68 Footwear Examination Type and condition of shoes / sandals Fit Shoe wear, pattern of wear, lining wear Foreign bodies Insoles, orthoses

69 WORK-UP LABORATORY INVESTIGATIONS : 1.Fasting or random blood sugar (FBS,RBS) 2.Glycohemoglobin (HbA1C) 3.Full blood count (FBC) 4.Erythrocyte sedimentation rates (ESR) 5.Serum chemistries (BUSE) 6.Wound and blood cultures(C&S) 7.Urinalysis (Urine FEME, C&S)

70 WORK-UP IMAGING STUDIES: 1.PLAIN RADIOGRAPHS 2.CT SCAN 3.RADIOISOTOPE TECHNETIUM 4.GALLIUM 67 CITRATE LEUKOCYTE SCAN 5.INDIUM 111 LEUKOCYTE SCAN 6.MRI

71 WORK-UP VASCULAR INVESTIGATIONS: Doppler segmental artery pressures. Ankle-brachial indices (ABI) – may be misleading due to calcification of the arteries giving rise to higher pressures at the ankle. Normal value 1.1, <0.9 abnormal. Toe pressure measurements (not readily available locally) – Less calcification in digital vessels enable toe pressures to be measured more accurately and be more reliable in the assessment of healing potential Transcutaneous oxygen tension (TcPO2)

72 Principles of Treatment Debridement of necrotic tissue Wound care Reduction of plantar pressure (off-loading) Treatment of infection

73 Principles of Treatment Vascular management of ischaemia Medical management of co morbidities Surgical management to reduce or remove bony prominences and / or improve soft tissue cover Reduce risk of recurrence

74 TREATMENTOF INFECTION PARAMETERSNON-LIMB THREATENINGLIMB THREATENING 1. Foot ulcer Superficial or subtle Deep and overt 2. Foot infection Mild to moderate, may arise from scratches, small punctures, fissures Severe, gangrene, necrotising fascitis and abscesses may be present 3. Cellulitis from ulcer < 2 cm > 2 cm 4. Osteomyelitis Absent, wound does not probe to joint or bone Present, wound probes to bone or joint 5. Clinical features Stable, no symptoms or signs of sepsis or systemic involvement Ill, with features of sepsis or systemic involvement. e.g. fever, hyperglycemia 6. Ischemia Absent Present, vascular consultation needed 7. HospitalizationNo, close supervision on outpatient basis Yes, required to treat infection and systemic involvement

75 TREATMENT OF INFECTION 1.surgical treatment 2.antibiotics treatment 3.wound care 4.treatment of metabolic and co-morbid problems

76 TREATMENT OF INFECTION 5.frequent reassessment of response of treatment 6.patient education 7.prevention 8.orthotics / prosthetic management

77 SELECTION OF LEVELS OF AMPUTATION THE CLASSICAL SITES OF AMPUTATION OF LIMBS WERE DETERMINED ON THE BASIS OF THE FOLLOWING CONSIDERATIONS: 1.The disease process for which the amputation was done to eradicate the pathology. 2.The vascular supply to the skin flaps. 3.The requirements of limb fitting procedures and techniques available at that time.

78 Suggested empirical antibiotic treatment for diabetic foot infection (Lipsky- Evidence based antibiotic therapy of diabetic foot infections, FEMS, Immun Med Micro 26 (1999) ) Severity of infectionRecommendedAlternatives Mild / Moderate (MONOMICROBIAL) Cephalexin Amoxcillin/Clavulanate Clindamycin Ofloxacin ± Clindamycin - Cotrimoxazole Moderate / Severe (POLYMICROBIAL) Ampicillin / Sublactam Clindamycin + Ciprofloxacin Trovofloxacin Metrodinazole + Ceftazidime Life threatening (POLYMICROBIAL) Imipenem / Cilastin Clindamycin + Tobramycin + Ampicillin Vancomycin + Aztreonam + Metronidazole

79 PREVENTION / PATIENT EDUCATION Take Care of Your Diabetes Check Your Feet Every Day Wash Your Feet Every Day Keep the Skin Soft and Smooth

80 PREVENTION / PATIENT EDUCATION Wear Shoes and Socks At All Times Protect Your Feet From Hot and Cold Keep the Blood Flowing to Your Feet Be More Active Communicate With Your Doctor

81 Monitor glucose level and administer insulin: o Every 4-6 hours if using regular insulin (rapid acting) o Every 2-4 hours if using lispro or aspart insulin (very rapid acting) For glucose level >250 mg/dl, check more frequently If after 4-6 hours no change in glycemic control is realized, consider insulin dosing according to next higher weight class SUBCUTANEOUS SLIDING SCALE VERY RAPID OR RAPID INSULIN ALGORITHM: TO SUPPLEMENT INSULIN REGIMEN ALREADY IN PLACE

82 Weight Class I (<175 lbs/80 kg) Weight Class II ( lbs/81-99 kg) Weight Class III (>220 lbs/100 kg) CBG (mg/dl) < >400 Insulin Units Begin Insulin Infusion Insulin Units Begin Insulin Infusion Insulin Units Begin Insulin Infusion

83

84 REFERENCES: 1.Frykberg RG, Armstrong DG, Giurini J, Edwards A, Kravette M, Kravitz S, Ross C, Stavosky J, Stuck R, Vanore J. Diabetic foot disorders: a clinical practice guideline. American College of Foot and Ankle Surgeons. J Foot Ankle Surg 2000;39(5 Suppl):S Frykberg RG. Diabetic foot ulcers: current concepts. J Foot Ankle Surg 1998;37: Hurvitz G, Zalavras C, Thordarson DB. Debridement and primary closure of nonhealing foot wounds. Am J Orthop Oct;33(10):507-9.Hurvitz GZalavras CThordarson DB 4.McElwain JP, Hunter GA, English E.Syme's amputation in adults: a long- term review. Can J Surg May;28(3):203-5.McElwain JPHunter GAEnglish E 5.Robbs JV, Ray R (1982) Clinical predictors of below knee stump healing following amputation for ischaemia. South African Journal of Surgery 20:

85 REFERENCES: 6.Andersen S, Gjedsted J, Christiansen C, Tønnesen E. The roles of insulin and hyperglycemia in sepsis pathogenesis. Journal of Leukocyte Biology. 2004;75: Brodsky, J: The Diabetic Foot. In Surgery of the Foot and Ankle, Coughlin, MJ, and Mann, RA, editors. Mosby Inc., St. Louis, Table 21-2, page http://som.flinders.edu.au/FUSA/ORTHOWEB/notebook/general/amputati ons.html#bkahttp://som.flinders.edu.au/FUSA/ORTHOWEB/notebook/general/amputati ons.html#bka 9.http://www.latrobe.edu.au/podiatry/diabetesresources/diabetes_lecture_4.htmhttp://www.latrobe.edu.au/podiatry/diabetesresources/diabetes_lecture_4.htm

86 MCQ 1.Which of the following Wagners Diabetic Ulcer Grade is characterized by a full- thickness ulcer? a. Grade 1 b. Grade 2 c. Grade 3 d. Grade 4 e. Grade 5

87 MCQ 1.Which of the following Wagners Diabetic Ulcer Grade is characterized by a full- thickness ulcer? a. Grade 1 b. Grade 2 c. Grade 3 d. Grade 4 e. Grade 5

88 MCQ 2. What area/s is/are the most common anatomical distribution of diabetic ulcers? a. Dorsum of the foot b. Ankle c. Multiple ulcers d. Toes e. Plantar metatarsal heads

89 MCQ 2. What area/s is/are the most common anatomical distribution of diabetic ulcers? a. Dorsum of the foot b. Ankle c. Multiple ulcers d. Toes e. Plantar metatarsal heads

90 MCR A if 1,2 & 3 are correct B if 1 & 3 are correct C if 2 & 4 are correct D if only 4 is correct E all of the above are correct

91 MCR 3.Which of the following are features of a limb threatening diabetic ulcer? 1. Cellulitis > 2 cm from ulcer 2. Wound does not probe joint or bone 3. With features of sepsis 4. Close supervision on an out-patient basis

92 MCR 3.Which of the following are features of a limb threatening diabetic ulcer? 1. Cellulitis > 2 cm from ulcer 2. Wound does not probe joint or bone 3. With features of sepsis 4. Close supervision on an out-patient basis

93 MCR 4.Which of the following antibiotic regimens can be given to a severe diabetic foot infection? 1. Amoxicillin/Clavulanate 2. Imipinem/Cilastin 3. Clindamycin + Tobramycin + Ampicillin 4. Ampicillin/Sulbactam

94 MCR 4.Which of the following antibiotic regimens can be given to a severe diabetic foot infection? 1. Amoxicillin/Clavulanate 2. Imipinem/Cilastin 3. Clindamycin + Tobramycin + Ampicillin 4. Ampicillin/Sulbactam

95 MCR 5.Which of the following laboratory examinations can assess the success of the level of amputation of a patient who underwent a major limb aputation? 1. FBS 2. ESR 3. CBG 4. HgbA1C

96 MCR 5.Which of the following laboratory examinations can assess the success of the level of amputation of a patient who underwent a major limb aputation? 1. FBS 2. ESR 3. CBG 4. HgbA1C


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