What's the Take Home?
A 67-Year-Old Woman With a Diabetic Foot Ulcer and Significant Anemia
Ronald N. Rubin, MD1,2—Series Editor
1Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
2Department of Medicine, Temple University Hospital, Philadelphia, Pennsylvania
Rubin RN. A 67-year-old woman with a diabetic foot ulcer and significant anemia. Consultant. 2020;60(11):20-22. doi:10.25270/con.2020.11.00003
The author reports no relevant financial relationships.
Ronald N. Rubin, MD, Temple University Hospital, 3401 N Broad St, Philadelphia, PA 19140 (email@example.com)
A 67-year-old woman is seen in the office a week after a long hospital admission for a variety of diabetes-related complications. She has had diabetes for 30 years, and her management has progressed from dietary changes to a variety of oral antidiabetes agents to, in recent years, injected insulin regimens.
About a month ago, she was admitted for further attempts to better manage her glycemic control and to address a nonhealing ulcer on her left heel. Evaluation revealed a deep ulceration of the left heel, with a probe appearing to touch bone. Plain radiographs and magnetic resonance imaging scans confirmed significant osteomyelitis of the left calcaneus. Interestingly and not surprisingly, there was minimal tenderness to the area, which was anesthetic to touch or pain on physical examination.
Two weeks ago, she underwent surgical debridement of the area. Culture results of a surgical specimen showed mixed aerobic and anaerobic organisms, and broad-spectrum antibiotics were initiated and are currently being continued at home with the assistance of a visiting nurse. During the hospital admission, consistent concerns demonstrated on blood studies were hyperglycemia, an elevated creatinine level of about 3 mg/dL, and persistent anemia, with a hemoglobin level initially measured at 8.0 g/dL and ranging between 7 and 8 g/dL, except for a briefly higher value after perioperative blood transfusion.
A battery of outpatient laboratory studies performed a day prior to the current clinic visit revealed the following values: blood glucose, 180 mg/dL; creatinine, 2.9 mg/dL; serum iron, 84 µg/dL; total iron binding capacity (TIBC), 200 µg/dL; serum ferritin, 84 ng/mL; and erythrocyte sedimentation rate (ESR), 92 mm/h. A complete blood cell count showed a hemoglobin level of 7.5 g/dL and a mean corpuscular volume of 79 µm3 with normal white blood cell (WBC) and platelet counts.
On physical examination, the patient was pale and ill-appearing but not in pain. Her major concern was fatigue essentially all the time, with moderate dyspnea with any exertion. Her blood pressure was 110/70 mm Hg, and her chest was essentially clear to auscultation. There was no lower extremity edema in her right foot, whereas the left foot was bandaged due to the presence of the surgically debrided heel ulcer.