Ospital ng Maynila Medical Center 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

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

CHIEF COMPLAINT NON-HEALING WOUND, FOOT, RIGHT

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

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

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

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-Koch’s, non- compliant

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

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

PHYSICAL EXAMINATION GENERAL SURVEY: conscious, coherent, NICRD BP= 120/ 80 CR= 78 RR= 22 T= 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

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

PHYSICAL EXAMINATION (lower extremities)

PHYSICAL EXAMINATION

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

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

SALIENT FEATURES 58/M 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 (+) DM Type II x 20 yrs, non-compliant to medications (+) History of previous amputation for diabetic gangrene of the left foot (2004-OMMC) (+) DM Type II both parents

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

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

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

CLINICAL DIAGNOSIS 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 10% MEDICAL

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

GOALS OF PARACLINICAL DIAGNOSTIC PROCEDURE DETERMINE THE DEPTH OF INFECTION

PARACLINICAL DIAGNOSTIC PROCEDURES BENEFIT RISK COST AVAILABILITY PLAIN RADIOGRAPHS ++ RADIATION EXPOSURE Php 150 +++ CT SCAN Php 3000-5000 TECHNETIUM BONE SCANS LESS SPECIFICITY RADIATION EXPOSURE Php 6000 + WHITE BLOOD CELL SCINTIGRAPHY HIGHLY SPECIFIC AND SENSITIVE NA MRI Php 10000-12000

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

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

GOALS OF TREATMENT REMOVAL OF NECROTIC TISSUE CONTROL OF THE INFECTION RESTORATION OF VASCULAR PERFUSION MEDICAL MANAGEMENT OF HYPERGLYCEMIA

TREATMENT OPTIONS – GOALS 1 TO 3 BENEFIT RISK COST AVAILABILITY DEBRIDEMENT* ++ FAILURE RATE= 71% RISK OF OPERATION Php 3000 +++ SYME’S / FOREFOOT AMPUTATION* FAILURE RATE= 49% MAJOR AMPUTATION (BELOW THE KNEE)* SUCCESS RATE= 92-99% Php 3000-5000 * ALL PROCEDURES REQUIRE ADEQUATE ANTIBIOTIC COVERAGE

TREATMENT OPTIONS – GOAL 4 BENEFIT RISK COST AVAILABILITY ORAL ANTIHYPER- GLYCEMIC AGENTS ++ Hypoglycemia Php 2000/wk +++ INSULIN (Indicated in patients with ongoing infection) Php 3000/wk

TREATMENT PLAN (SURGICAL) BELOW THE KNEE AMPUTATION, RIGHT

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

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

PRE-OP PREPARATION FLUID RESUSCITATION 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

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

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

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

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

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

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

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

OPERATION DONE BELOW THE KNEE AMPUTATION, RIGHT

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

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

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

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

FOLLOW-UP PLAN REMOVAL OF SUTURES AFTER 10-14 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

SHARING OF INFORMATION DIABETIC FOOT

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)

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)

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

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

Depth-Ischemia Classification of Diabetic Foot Lesions DEPTH CLASSIFICATION DEFINITION TREATMENT At-risk foot, no ulceration Patient education, accommodative footwear, regular clinical examination 1 Superficial ulceration, not infected Offloading with total contact cast (TCC), walking brace or special footwear 2 Deep ulceration exposing tendons or joints Surgical debridement, wound care, offloading, culture-specific antibiotics 3 Extensive 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, 1999. Table 21-2, page 911.

Depth-Ischemia Classification of Diabetic Foot Lesions DEFINITION TREATMENT A Not ischemic B Ischemia without gangrene Noninvasive vascular testing, vascular consultation if symptomatic C Partial (forefoot) gangrene Vascular consultation D Complete foot gangrene Major extremity amputation, vascular consultation

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

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

PRECIPITATING EVENTS THAT INCREASE RISK FOR TISSUE DAMAGE Accidental cuts Shoe trauma Repetitive stress Thermal trauma Iatrogenic Vascular occlusion Skin or nail conditions

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)

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

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

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)

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

HISTORY GENERAL FOOT-SPECIFIC WOUND / ULCER HISTORY

PHYSICAL EXAMINATION MUSCULOSKELETAL DERMATOLOGIC VASCULAR NEUROLOGIC FOOTWEAR

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

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

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

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

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

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

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

WORK-UP IMAGING STUDIES: PLAIN RADIOGRAPHS CT SCAN RADIOISOTOPE TECHNETIUM GALLIUM 67 CITRATE LEUKOCYTE SCAN INDIUM 111 LEUKOCYTE SCAN MRI

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)

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

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

TREATMENTOF INFECTION PARAMETERS NON-LIMB THREATENING LIMB 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. Hospitalization No, close supervision on outpatient basis Yes, required to treat infection and systemic involvement

TREATMENT OF INFECTION surgical treatment antibiotics treatment wound care treatment of metabolic and co-morbid problems

TREATMENT OF INFECTION frequent reassessment of response of treatment patient education prevention orthotics / prosthetic management

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

Suggested empirical antibiotic treatment for diabetic foot infection (Lipsky- Evidence based antibiotic therapy of diabetic foot infections, FEMS, Immun Med Micro 26 (1999) 267-276)  Severity of infection Recommended Alternatives   Mild / Moderate (MONOMICROBIAL) Cephalexin Amoxcillin/Clavulanate Clindamycin Ofloxacin  ± -    Cotrimoxazole Moderate / Severe (POLYMICROBIAL) Ampicillin / Sublactam Clindamycin + Ciprofloxacin Trovofloxacin Metrodinazole + Ceftazidime Life threatening Imipenem / Cilastin Clindamycin + Tobramycin +       Ampicillin Vancomycin +        Aztreonam +        Metronidazole

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

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

Monitor glucose level and administer insulin: SUBCUTANEOUS SLIDING SCALE VERY RAPID OR RAPID INSULIN ALGORITHM: TO SUPPLEMENT INSULIN REGIMEN ALREADY IN PLACE 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 Weight Class I (<175 lbs/80 kg) Weight Class II (175-220 lbs/81-99 kg) Weight Class III (>220 lbs/100 kg) CBG (mg/dl) <150 150-200 201-250 251-300 301-350 351-400 >400 Insulin Units 1 2 4 6 8 Begin Insulin Infusion 10 12

REFERENCES: 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):S1-60. Frykberg RG. Diabetic foot ulcers: current concepts. J Foot Ankle Surg 1998;37:440-6. Hurvitz G, Zalavras C, Thordarson DB. Debridement and primary closure of nonhealing foot wounds. Am J Orthop. 2004 Oct;33(10):507-9. McElwain JP, Hunter GA, English E.Syme's amputation in adults: a long-term review. Can J Surg. 1985 May;28(3):203-5. Robbs JV, Ray R (1982) Clinical predictors of below knee stump healing following amputation for ischaemia. South African Journal of Surgery 20: 305-10

REFERENCES: Andersen S, Gjedsted J, Christiansen C, Tønnesen E. The roles of insulin and hyperglycemia in sepsis pathogenesis. Journal of Leukocyte Biology. 2004;75:413-421. Brodsky, J: The Diabetic Foot. In Surgery of the Foot and Ankle, Coughlin, MJ, and Mann, RA, editors. Mosby Inc., St. Louis, 1999. Table 21-2, page 911. http://som.flinders.edu.au/FUSA/ORTHOWEB/notebook/general/amputations.html#bka http://www.latrobe.edu.au/podiatry/diabetesresources/diabetes_lecture_4.htm

MCQ Which of the following Wagner’s 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

MCQ Which of the following Wagner’s 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

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

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

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

MCR 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

MCR 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

MCR 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

MCR 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

MCR 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

MCR 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