Ophthalmology Case Study

HISTORY
Patient is a 58-year-old male who comes in with a long history of diabetic foot ulcer that has not healed.  He has been through wound therapy, but it just stays there, but has been dry.  States about a week ago, it started oozing more and now he has got redness all over the MTP area of his foot, and he has got a secondary ulcer medially that has broken through.  I think this is an extension of his cellulitis.  He has had his great toe removed approximately 1 year ago.  He also had a 2nd metatarsal of his left foot removed in 2005 by Dr. Todd.  He states his ______ and he has been keeping his sugars a lot better and indeed he has, his last hemoglobin A1c was 6.5.

ALLERGIES

He has no known allergies.

CURRENT MEDICATIONS

Humulin 70/30, 20 units in the morning, 20 units in the evening.

He says his sugars run well.  He only checks about once a week secondary to financial restrictions.  He is now out of a job.  He was laid off by Sams when they had to cut back.  He had diabetes for years, but has never really taken care of himself to this point.  He started to have problems and he got series about 3 years ago.  Unfortunately, he has had these complication.

FAMILY HISTORY

At this time, is noncontributory.

SOCIAL HISTORY

He is divorced.  They have 1 adopted child together.  He does not smoke, does not drink.  He does some side computer jobs.

OBJECTIVE

EXTREMITIES:  When I see Mr. Case, he comes in walking on the side of his right foot.  His right MTP and bottom of his foot is red and erythematous.  The ulcer is not much draining out of, but it has got a black eschar above it, but on the medial aspect of the MTP, there is a hole that is draining kind of serosanguineous fluid.

ENT:  His pupils equal, round, reactive to light.  His extraocular movements are intact.  His TMs are clear.

CHEST:  Clear.

CARDIAC:  Regular rate and rhythm.

ABDOMEN:  Soft.  He has lost a lot of weight when he got serious about his sugar.  Over the last 2 years, he has lost close to 70 to 80 pounds.  He lost a lot secondary to uncontrolled diabetes, which has resulted in 2 previous amputations.

ADMISSION DIAGNOSES

1.            Diabetic foot ulcer with cellulitis, suspect osteomyelitis for the secondary tract of an ulcer going to medial aspect of the foot.

2.            Insulin-dependent diabetes.  Last hemoglobin A1c was fine.

3.            Poor overall well being secondary to social restrictions of finances.  He is now living by himself.  He will make his own meals.

4.            Diabetic neuropathy.

PLAN

At this time, we will admit to the hospital.  We are going to start him on IV Zosyn 4.5 g q.8 h.  We will get wound culture.  Put Bactroban ointment on twice a day.  Consult Dr. Todd.  We will continue his glucose previous regimen.