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Trouble behind her back

01 May 2012

Housekeeper Mrs L, 58, was a poorly-controlled diabetic patient who was well-known to her GP, Dr V. One day, she presented with a swollen foot, and Dr V discovered an extensive area of skin breakdown on the ball of the foot discharging purulent fluid. He diagnosed an infected diabetic ulcer and referred her immediately to hospital.

At hospital the ulcer was debrided and she was treated with intravenous antibiotics. The diabetes multidisciplinary team reviewed her diabetes management and warned her several times that she might need an amputation. Fortunately, the infection was controlled, the tissues remained viable and amputation was not needed. She was then discharged for ongoing care in the community.

Mrs L continued to make progress as the ulcer gradually resolved, but during the recovery period she developed pleuritic chest and back pain. Dr V saw Mrs L several times at home and in surgery and diagnosed this as a chest infection. Each time he took time to carefully document Mrs L’s symptoms and his management.

One month following her hospital admission, Mrs L developed severe back pain and acute urinary retention. She was admitted as an emergency admission to hospital, where investigations revealed vertebral osteomyelitis at T10 with spinal cord compression and an epidural abscess. In spite of aggressive treatment Mrs L was left with paraplegia.

Mrs L made a claim against the hospital and Dr V for a delay in diagnosis of the abscess, which caused her paralysis. Expert opinion reviewed the medical notes, which included details of every visit, and were strongly supportive of Dr V’s management. The case was successfully defended.

Learning points

  • Complications can, and do, occur in almost any clinical scenario, even when treatment is meticulous.
  • Comprehensive and contemporaneous notekeeping is vital and the foundation of good practice.
  • Infections are a significant problem in diabetes, especially when their control is poor. Microvascular and macrovascular complications of diabetes, as well as defects in cell-mediated immunity, increase with age, so increasing the risk of infection. Infections may also disrupt metabolic homeostasis and glycaemic control, so prompt recognition and treatment is therefore critical. Access a good overview here.
  • The importance of good foot care should be emphasised to patients – diabetic foot complications are the most common cause of non-traumatic lower extremity amputations in the industrialised world. Early detection and appropriate treatment of diabetic ulcers may prevent up to 85% of amputations. There is useful advice at:
  • There may be an identifiable nidus from which the infection seeds through the blood stream, but 30-70% of patients with vertebral osteomyelitis have no obvious prior infection. Read more on the management of spinal infections on the Medscape website.
  • Medicines used to treat the primary infection can obscure the presentation of symptoms from complications elsewhere, eg, a prolonged course of antibiotics and painkillers used to treat an infected diabetic foot ulcer may temper signs of infection elsewhere, rendering the secondary infection occult.