Case 109: Outpatient Care of Osteomyelitis and Cellulitis in Man with Neuropathic Foot

On November 4th, 1987 at age 54, this type 2 diabetic man was referred with palpable pulses, plantar callus and varices. He was provided with diabetic guidance and sheets describing proper diabetic foot care. He returned to his family doctor with a glycohemoglobin of 7.2%.

He was referred again on December 9th, 1990 with a large plantar ulcer exposing a black tendon. His pulses were still easily palpable in the feet but he could not feel a 6.10 fiber. His glycohemoglobin was 8.3%.

Abundant Pseudomonas aeruginosa were recovered from the ulcer.

He was treated with Sea Soaks, Ticar, gentamicin and Urecholine in the Mini-Boot bath. He was treated six of the next eight days as an outpatient and appeared to be doing well.

January 15th, 1991: His ulcer was closing nicely. Then, he disappeared for two weeks.

He returned with a red fluctuant foot and a temperature of 100.8 degrees F.

Xrays showed osteomyelitis involving the second metatarsal and first and second proximal phalanges. Vancomycin was added to both his local injections and his Sea Soaks Mini-Boot bath. He was treated on weekdays for the next three months. He disappeared again in April after the photographs below. He had been treated as an outpatient because he had no insurance. He subsequently declared bankruptcy. His feet were healed at our last contact. In debt to our office, he now seeks what care he might need elsewhere.

April 17th, 1991.

Fully ambulatory at this time, he was soon to disappear again.

Comments: This man did well by us. In many centers, he would have lost his leg. His financial straits compromised his care. Unfortunately, the boot doctor cannot absorb too many financial losses like this one; the boot technicians and the boot room nurses demand their salaries and the druggists do not supply antibiotics for nothing. Patients like this man tend to have recurrent problems. It is a shame that he is lost to our care..