Mr. S. S. is a 56 year old, white male with a right diabetic foot ulcer. He was at his podiatrist’s office for a wound check and was referred to the emergency department (ED) due to increasing purulent drainage and necrotic tissue in the wound. Mr S.S. noticed the drainage getting worse over the last week and has experienced fevers up to 102 degrees F for two days. He also complains of diaphoresis, fatigue, abdominal pain, and general malaise. He states he just does not feel like himself.
Past Medical History:
Allergic to Penicillin and shellfish
Uncontrolled Type 2 Diabetes Mellitus
Hyperlipidemia
Hypertension [baseline 140/90]
Obesity [BMI=32]
Cholecystectomy, age 32 years
Left Above the Knee Amputation (AKA), age 54 years
Pertinent Family History:
Mother- Hyperlipidemia, Hypertension, CABG x2 vessels
Father- Prostate Cancer, age 63 years
Pertinent Social History:
Active Smoker (2 packs/day)
History of Alcoholism
Previous history of homelessness
Emergency Department
In the ED, assessment reveals moderate, foul-odored, purulent drainage from right foot ulcer and capillary refill of four seconds on upper and lower extremities. Patient is alert and oriented but short term memory appears to be impaired and the patient is asking abnormal questions. Two peripheral IVs and an indwelling foley catheter are placed, a 1000mL bolus of IVF is initiated, wound and blood cultures are obtained, and the patient is started on broad spectrum antibiotics. A x-ray of his right foot demonstrates soft tissue inflammation and concern for osteomyelitis so an MRI was completed of his foot. The patient is transferred to MICU for further management.
ED Vitals:
Temperature: 101.6 degrees F
Heart Rate: 117 bpm
Respiration Rate: 24 breaths/min
Blood Pressure: 92/45 mm Hg (MAP 61)
Blood glucose: 315 mg/dL
SpO2: 91% on 2L NC
ED Labs:
WBC: 26,000
Lactate: 6.0 mmol/L
C-reactive Protein: 11mg/L
Creatinine: 1.4 mg/dL
pH: 7.32
Medical Intensive Care Unit
Upon admission to MICU, Mr. S.S. is lethargic and flushed. Further assessment demonstrates bounding pulses and right lower extremity edema. His heart rate increased and blood pressure dropped despite the liter bolus. The patient is started on vasopressors to maintain his blood pressure and intubated to protect his airway.
Pertinent Vitals:
Temperature: 101.4 degrees
Heart Rate: 154 bpm
Respiration Rate: 30 breaths/min
Blood Pressure: 72/34 (MAP 47)
SpO2: 86% on 2L NC