Aashi
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A 64-year-old woman comes to the emergency department because of a non- healing ulcer in the right foot. She is a known insulin-dependent diabetic, is hypertensive, and is on dialysis for chronic renal failure. She noticed an ulcer in the plantar aspect of her foot a week ago following a hike on marshy grounds. She started taking oral antibiotics that she had at home from a past illness. However, since yesterday, she has noticed a foul smelling discharge from the ulcer, along with foot swelling and fever. Her temperature is 39.1 C (102.4 F), blood pressure 140/68 mm Hg, and pulse 88/min. Local examination of the right lower extremity shows swelling of the lower leg and foot with crepitus. A 3x2 cm. ulcer at the base of the great toe is noticed on the plantar aspect with foul smelling serous brownish discharge. Lower extremity pulses are diminished bilaterally. Laboratory studies show:
The most appropriate next step in management to limit disability is to
A. administer insulin and send her home with oral antibiotics
B. order foot and leg x-rays
C. perform incision and drainage of the ulcerated area
D. provide intravenous antibiotics
E. repeat serum potassium level
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| sprint123
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Is it C?
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| dr.wad
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where is the labs .?
however ( C ) for gas gangrene.
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| hero
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d?
it is not looks like gas gangrene (her vitals)
Gas in the soft tissues is neither sensitive nor specific for gas gangrene.
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| Ivonne
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I think this patient may have necrotizing fasciitis therefore antibiotic treatment should be ASAP then C
i will go with D as a next step
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| tamerbashir
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C
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| Aashi
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The correct answer is B. 
Diabetic foot ulcers, when inadequately treated, can result in wet gangrene and necrotizing infections. Serous brownish discharge, swelling of foot and leg with crepitus, fever, and high leukocyte counts, are hallmarks of a necrotizing infection in a diabetic foot. Immediate foot and leg x-rays are essential to diagnose subcutaneous air and to delineate the level of spread. Following this, the patient should be taken to the operating room for a wide debridement or even an amputation depending upon the extent of necrosis of the tissues.
Control of blood sugar is essential for proper wound healing in a diabetic, but the removal of the source of infection is important in preventing further complications of infection (choice A). In this patient, administering insulin and antibiotics are essential, but surgical debridement is more important in limiting the disability. She requires further evaluation and treatment and should not be sent home.
Simple incision and drainage (choice C) is not adequate in treating a necrotizing infection.
This patient is already taking antibiotics at home.
Although she needs intravenous antibiotics (choice D) for better control of the infection, surgical debridement of the foot is the first essential step to control the damage and limit disability.
High serum potassium level is a consequence of her chronic renal failure and increased cellular lysis in this necrotizing infection. Without controlling further spread of infection, serum potassium level is bound to increase and can cause cardiac dysrhythmias. To limit the disability, removal of the source of high potassium level is essential rather than repeating potassium level (choice E).
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| RX 135
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x ray to rule osteomyelitis very imp
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| Korotkoff
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Nice question. I was jumping to grab C.
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