(Disclaimer: This article is for scientific use only, and relevant information in the following content has been processed to protect patient privacy)
Abstract: This is a case of a female patient with a 26-year history of diabetes mellitus who developed complications due to poor daily glycemic control. This time, Charcot’s foot due to severe diabetic neuropathy was not detected and actively treated in the early stage, resulting in multiple fractures of the foot and loss of limb preservation. After surgery and medication, the patient’s condition was controlled and her blood glucose and all inflammatory indicators improved.
Basic information】Female, 62 years old
Disease Type】Diabetes mellitus, diabetic foot disease
Hospital】The First Affiliated Hospital of Anhui Medical University
Date of Consultation】August 2021
Treatment plan】Medication (arginine recombinant human insulin mixed injection + menthol insulin injection + prostaglandin injection + lipoic acid injection + pancreatic kininogenase for injection + adenosine cobalamin for injection + cefazoxime sodium for injection + ticoranine for injection) + debridement + surgery (amputation)
Treatment Period】Hospitalization for 20 days, outpatient review after 1 month
Treatment effect] The condition was controlled, and the blood sugar and inflammatory indexes improved
I. Initial consultation
The patient was diagnosed with diabetes mellitus 26 years ago and had been treated with subcutaneous insulin injections for nearly 20 years, with little blood glucose monitoring. Five days ago, the patient developed a fever, with a maximum temperature of 38.5°C. The left foot was highly swollen, with elevated skin temperature and collapsed arches. WBC: 13.66×10^9/L, 79.24% neutrophils, considering the patient’s diabetic foot was very serious, the patient was hospitalized immediately.
II. Treatment process
After admission, the patient underwent blood glucose monitoring and found that the control was not particularly bad. The patient continued to implement an intensive insulin hypoglycemic regimen, using a mixture of arginine recombinant human insulin injection and combined with menthol insulin injection subcutaneously every day. The patient’s foot was also quickly evaluated, and prostaglandin injection and lipoic acid injection were first given daily intravenously, and injectable pancreatic kininogenase and injectable adenosylcobalamin were given intramuscularly. The diabetic foot with infection was treated with debridement + antibiotic application, i.e., cefazoxime sodium for injection combined with teicoplanin for injection. The patient’s left foot CT showed that the left foot cuneiform, dice, navicular and proximal metatarsal bones were dislocated with localized soft tissue ossification changes and subcutaneous infectious lesions on the dorsum of the foot. The lesion was more serious, so a hospital-wide discussion was arranged and it was finally concluded that this was a severe diabetic foot due to unrecognized and unbraked acute phase of Charcot’s foot, with little significance for limb preservation, and amputation was recommended to preserve life. After discussion with the patient, amputation was performed in the orthopedic department. After surgery, the patient’s temperature was normal and the wound healed well, and he was subsequently transferred back to the endocrinology department.
III. Treatment results
The patient was scientifically evaluated and actively treated. Firstly, in the case of infection, the patient was an elderly diabetic patient and the insulin multiple subcutaneous injection protocol was clarified, and the blood glucose was well controlled in time. With good glycemic control as the basis, complication assessment was actively carried out, especially for the complex diabetic foot, and after multidisciplinary consultation, a treatment plan was precisely formulated. After taking surgical amputation, the patient’s body temperature was normal, WBC decreased from preoperative: 13.66×10^9/L to 9.11×10^9/L, inflammation index CRP and calcitoninogen were recovered, and the patient’s basic condition was good The patient was discharged at 20 days of hospitalization and was asked to come back for a review in 1 month. At the time of review, the patient indicated that no other uncomfortable symptoms appeared and no significant abnormalities were seen at the surgical site.
IV. Precautions
After treatment, the patient’s condition was controlled and the indicators improved, so we are truly happy for him. Since the patient is an elderly diabetic patient who has just undergone surgery, it is recommended to enhance nutrition after surgery, but also to control the total calories, and it is recommended to enhance the intake of protein and high-fiber foods to avoid poor glycemic control, which may affect wound healing.
Since there are restrictions on postoperative exercise for elderly diabetic patients and they need to be bedridden, upper limb exercise is recommended, while empty bicycle is recommended for lower limbs, which can strengthen muscle exercise on the one hand and prevent thrombosis on the other.
It is also recommended that patients should actively inject insulin for treatment after going home, and family members should also learn to use blood glucose meters to give patients multi-point blood glucose monitoring to prevent the occurrence of hypoglycemia.
V. Personal insight
Diabetic complications do not appear overnight. For elderly diabetic patients, due to the long duration of the disease, they should pay more attention to blood glucose, and pay attention to the prevention and control of complications. In addition, it is important to master the principle of the five horses, namely diet control, exercise combination, medication, blood glucose monitoring and diabetes education, and screening for complications is not negligible and should be done annually. Avoid rarely monitoring blood glucose as this patient did, which led to the aggravation of discomfort, which was controlled after the surgery.