A 55-year-old woman with uncontrolled diabetes presented with a swollen and painful right foot along with fever for one week. Examination revealed an ulcer on the top and bottom of her right foot with sloughing and exposed tendons. She underwent amputation of toes 2-4 on her right foot due to worsening symptoms.

1. ODL 5

2. Chief complaint
• Mdm. N, a 55 years old Malay lady with underlying uncontrolled
diabetes mellitus presented to emergency department with
complaint of swelling over right foot associated with fever

3. HOPI
Swelling
• Sole of the right foot
• Started one week ago
• Localised, warm to touch, redness
• Initially, it was small but then progressively increase in size
• However, it was painless and she was still able to ambulate at home
and working as usual
• No pus discharge, no bleeding, no punctum

4. Fever
• On and off since one week ago
• No body temperature recorded at home
• It was temporarily relieved by paracetamol
• However, there was no chills and rigor, no malaise and no profuse
sweating

5. • One week after the onset of swelling and fever, her condition became
worse
• She went to private clinic for help
• Intravenous antibiotic and oral paracetamol was given
• But on the next day, she had worsening fever associated with chills
and rigor.
• She went to emergency department and was warded after that

6. Otherwise,
• No other symptoms such as shortness of breath, cough, nausea and
vomiting, urinary symptoms
• No hx of trauma, fall, insect bite, self prick

7. Systems Findings
General She has fever, chills and rigor.
No loss of appetite, no loss of weight
Respiratory System No runny nose, no cough, no shortness of breath
Cardiovascular System No profusely sweating, no cyanosis, no shortness of breath, no pallor, no chest
pain
Central Nervous System No loss of consciousness, no malaise, no visual disturbance or headache.
Genitourinary System No dysuria, no urinary incontinence, no nocturia, no hematuria, no urgency.
Gastrointestinal System No abdominal pain, no nausea & vomiting, no change in bowel habit, no
heartburn, no change in stool colour.
H & L System No bleeding tendency, no easily bruising.
Musculoskeletal System No myalgia, no joint pain or stiffness, no muscle weakness, no hands and legs
deformity.

8. Past Medical and surgical history
• Diagnosed in January 2018 at private clinic
• She was not compliance to her oral metformin and did not have any
follow up
• She did not do any home glucose monitoring
• She bought her medication over the counter from pharmacy
• She had experienced numbness in lower limbs. However, there was
no blurry vision, denied having polyuria, polydipsia, nocturia and
frothy urine.
• She had no other chronic illnesses such as hypertension and
dyslipidemia
• There was no previous history of hospitalization or surgery

9. Drug history
• She is currently on metformin but not compliance
• She also took traditional medication since long time ago as her
energy booster
Allergy history
• She had no known of any allergy.

10. Family history
• Her parents passed away due to unknown causes
• She is the youngest among three siblings
• Both of her siblings are well and healthy
• She has 5 children and all are healthy
• Otherwise, there was no family history of diabetes mellitus,
hypertension or dyslipidemia, no family history of malignancy

11. Social history
• She is non-smoker and non-alcoholic drinker
• She is married and currently stay with her eldest son who takes care
of her at home
• They live at flat house, floor 16th with full amenities but there was
frequent lift problem
• Her husband passed away at age of 65 years old due to pneumonia
• She works as housekeeper with monthly income around RM1500 and
also financially supported by her children

12. Physical examination
She was lying comfortably in supine position supported with one pillow. She
was conscious, alert and not in respiratory distress. There was a branula
inserted on her dorsum of left hand connected to antibiotic infusion
Anthropometry measurements
Body weight : 62kg
Body height : 155cm
Body Mass Index : 25.83 kg/m²
Interpretation : She is overweight.

13. Vital sign
• Blood pressure: 107/69 mmHg
• Pulse rate: 94 beats/min
• Respiratory rate: 18 breaths/min
• Temperature: 38.0˚C
• Pain score : 3/10
Interpretation : She was febrile and other vital signs were normal.

14. Ulcer examination

15. Lower limb
neurological
examination
Left Lower Limb Right Lower Limb
Tone Normal tone Normal tone
Power L2 : 5/5
L3 : 5/5
L4 : 5/5
L5 : 5/5
S1 : 5/5
L2 : 5/5
L3 : 5/5
L4 : 3/5, power reduced due to pain
L5 : 2/5, power reduced due to pain
S1 : 3/5, power reduced due to pain
Range of
Motion
Range of motion of left leg is full.
Knee flexion : 0-130 degree
Knee extension : 0-10 degree
Range of motion of right leg is full.
Knee flexion : 0-130 degree
Knee extension : 0-10 degree
Reflex All the reflexes are normal Knee jerk is present.
Ankle jerk cannot be tested due to pain.
Sensation L2, L3, L4, L5 and S1 sensations are all
intact
L2 and L3 sensations are intact.
L4, L5 and S1 sensations cannot be tested
as there is an ulcer.
Pulses All the pulses are palpable. Popliteal pulse is palpable.
Dorsalis pedis artery and posterior tibial
pulses cannot be assessed.

16. Clinical summary
Mdm. N, a 55 years old Malay lady with underlying uncontrolled
diabetes mellitus complaint of right foot swelling associated with fever,
currently post-op day 1 ray amputation of 2nd, 3rd and 4th toes of
right foot. On physical examination, there was an ulcer on dorsum and
plantar of right foot with area of slough and exposed tendons and
muscles.