1. Ms. G. presents with cellulitis of the left leg – this is noted by lab results that indicate infection such as increased WBC, bands >10%, and an 80% left shift of her neutrophils. Ms. G. also has swelling and erythema of her left leg, is unable to bear weight, and is running a temperature. Ms. G. needs more lab work (CMP, ABG, Hgb A1C,CK,  lactic acid, procalcitonin, CRP, pan cultures, and an MRI or CT of left leg), as well as additional vital signs. When a patient is septic their HR is either increased or decreased, patient is generally hypotensive, and patient is tachypneic. Because Ms. G. is diabetic she needs an ABG and CMP to see if she has DKA due to the infection, and an A1C to see how well controlled her blood sugars are. CK should be checked to see if Ms. G. is in rhabdo due to muscle breakdown and possible DKA. Lactic acid and procalcitonin are indicators for sepsis and is something that should be done immediately upon suspecting sepsis. Patient should be pan cultured, however, or at the very least 2 sets of blood cultures should be done prior to starting antibiotics. CRP will be elevated due to the infection and is not a specific test but will show that she has inflammation. MRI or CT to evaluate if there are any other problems associated with her infection other than cellulitis.  Preferably an MRI as it will give better results. Surgery consult should be ordered also. Recommended treatments consist of: IV antibiotics, possible sepsis and dka protocols, as well as possible surgery. Ms. G. also needs to have a wound consult for the wound on her left ankle and an appropriate dressing applied. Marking the margin of the red area is recommended in order to determine if the site has expanded, as well as, measuring ble to see the extent of the swelling. Elevation of left leg above the level of the heart if possible.
  2. The muscle groups affected are: Lower leg: gastrocnemius, soleus, extensor digitorum, extensor hallucis longus, extensor hallucis brevis, tibialis posterior. Possible muscles affected in upper leg: gracilis, semimembranosus, bicep femoris, vastus lateralis, rectus femoris, Sartorius, tensor fasciae latae, and adductor longus. Listing muscle groups that are affected is challenging due to the seriousness of the infection. All of the muscle groups in the upper and lower leg could be affected.  While these are all skeletal muscles each of our organs are considered muscles also and when a patient is septic each one can be affected leading to multiorgan system failure.
  3. The significance of the data provided shows that Ms. G. has an infection, is likely septic r/t to cellulitis of the left leg, as well as dka, and will probably need to be admitted to the hospital for IV antibiotics, possible insulin infusion and to be stabilized. Follow up labs are listed above and patient should be having a regularly scheduled Hgb A1C with her primary care physician. Patient needs more education on managing her diabetes and proper skin care, especially foot care since she is diabetic. Patient should be seeing a wound nurse for the wound on her ankle, and a podiatrist to have her feet checked and nails cut. Patient also needs to see a diabetic educator and nutritionist to help her understand DM and to help her with a plan of care for weight loss and blood sugar control. Patient also needs homecare and a program such as Meals on Wheels that will deliver her meals for her, at least until she has recovered. If homecare is not an option and she is unable to care for herself at home then placement in a skilled nursing facility is recommended.
  4. Ms. G. is diabetic and this will prevent wound healing. Ms. G. also has a wound on her left ankle that needs to be addressed. Ms. G. needs a significant amount of education and to be seeing specialists. If Ms. G. does not have a proper diet then her wound healing will be delayed also. While nutrition is important long term for her it is also important to help her heal from her current state. DM is a serious disease with debilitating side effects if not managed properly. Uncontrolled DM can lead to organ failure, blindness and loss of limbs.

 

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