Case Study: Sherman “Red” Yoder – Open Foot Wound Rated 100 % correct

Patient Profile • Name: Sherman “Red” Yoder • Age: 68 • Gender: Male • Occupation: Retired farmer / Part-time carpenter • Medical History: Type 2 diabetes (diagnosed 15 years ago), peripheral neuropathy, hypertension, obesity (BMI 32) • Social History: Lives alone on a small farm; has a 20-pack-year smoking history (quit 5 years ago); limited family support nearby. Chief Complaint “I noticed a sore on the bottom of my right foot about two weeks ago. It’s getting bigger and draining some yellowish fluid.” Present Illness Red stepped on a small nail while cleaning his barn approx. 2 weeks ago. He felt no immediate pain due to diabetic neuropathy. He cleaned the wound with water and covered it with a bandage. Over the past 5 days, he noticed increasing redness, swelling, and a foul-smelling discharge. He reports feeling “run down” with occasional chills but no fever at home. He continued to walk on the foot, believing it would heal on its own.Physical Examination (Selected Findings) • Vitals: BP 142/88, HR 102, RR 18, Temp 99.8°F (37.7°C) oral • Right Foot: o 4 cm x 3 cm ulceration on plantar surface of the 1st metatarsal head o Wound edges: irregular, undermining at 2 o’clock (approx. 1.5 cm) o Base: 70% yellowish slough, 30% red granulation o Drainage: Moderate, purulent, malodorous o Surrounding skin: Erythematous, warm to touch, mild edema extending to ankle o Sensation: Diminished to monofilament testing o Pulses: Dorsalis pedis and posterior tibialis palpable but weak (1+/4+ bilaterally) Diagnostic Data • Laboratory: o WBC: 13.5 K/uL (elevated) o HbA1c: 9.2% (poorly controlled diabetes) o ESR: 55 mm/hr; CRP: 28 mg/L (elevated) o Blood glucose (random): 235 mg/dL • Wound Culture: Staphylococcus aureus (MSSA) and Proteus mirabilis • Imaging: X-ray right foot – soft tissue swelling; no osteomyelitis seen. MRI recommended to rule out deep space infection. Problem List 1. Infected open foot ulcer (probable moderate to severe infection, no osteomyelitis yet) 2. Uncontrolled type 2 diabetes (HbA1c 9.2%)3. Peripheral neuropathy with loss of protective sensation 4. Risk for falls and further injury 5. Social isolation / limited caregiver support Nursing & Interdisciplinary Management (First 48 hours) • Wound Care: o Surgical debridement of slough and callus at bedside (or OR if extensive) o Irrigation with normal saline; packing with calcium alginate or antimicrobial dressing (silver or iodine-based) o Offloading: Total contact cast or removable walker with full foot offloading • Infection Control: o IV antibiotics (Vancomycin + Piperacillin-Tazobactam) pending final C&S; then tailored to MSSA + Proteus o Daily monitoring for signs of sepsis (q4h vitals, lactate if indicated) • Glycemic Management: o Endocrine consult; adjust insulin regimen (basal-bolus) o Glucose checks AC and HS; maintain target 140–180 mg/dL in acute setting • Pain Management: o Gabapentin for neuropathic pain; acetaminophen for mild inflammatory pain (avoid NSAIDs due to possible renal risk) • Patient Education: o Daily foot checks (use mirror if needed) o Never walk barefoot o Signs of infection to report immediately o Importance of glycemic control for wound healing