1. 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

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-Koch’s, 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= 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

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
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

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. 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

19. 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

20. 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

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
BENEFIT
RISK
COST
AVAILABILITY
PLAIN RADIOGRAPHS ++
RADIATION
EXPOSURE
Php 150
+++
CT SCAN
Php
TECHNETIUM BONE SCANS
LESS SPECIFICITY
RADIATION EXPOSURE
Php 6000 +
WHITE BLOOD CELL SCINTIGRAPHY
HIGHLY SPECIFIC AND SENSITIVE NA
MRI
Php

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

27. 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
* ALL PROCEDURES REQUIRE ADEQUATE ANTIBIOTIC COVERAGE

28. 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

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 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

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. DIABETES MELLITUS TYPE II
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 3RD POD: 1. LIVE
2. WITH NO COMPLICATION
3. SATISFIED
4. WITH NO MEDICO-LEGAL SUIT

45. 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

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 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.

51. 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, Table 21-2, page 911.

52. 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

53. 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

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
Accidental cuts
Shoe trauma
Repetitive stress
Thermal trauma
Iatrogenic
Vascular occlusion
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 (AGE’s/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 MUSCULOSKELETAL DERMATOLOGIC VASCULAR NEUROLOGIC
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 :
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)

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

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

76. TREATMENT OF INFECTION
frequent reassessment of response of treatment
patient education
prevention
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:
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.

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 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

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:
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

82. 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
( lbs/81-99 kg)
Weight Class III
(>220 lbs/100 kg)
CBG (mg/dl)
<150
>400
Insulin Units 1 2 4 6 8
Begin Insulin
Infusion 10 12

84. 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 Oct;33(10):507-9.
McElwain JP, Hunter GA, English E.Syme's amputation in adults: a long-term review. Can J Surg 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:

85. REFERENCES:
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 911.

86. 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

87. 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

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
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
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
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
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
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
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