Javeed Akhtar is a 69-year-old and presenting to the emergency department with a right foot ulcer affecting the 3rd, 4th and 5th toes. Mr. Akhtar prefers to be called Javeed and identifies as a cis-gender man. Javeed states that he thinks the ulcer was caused by him stubbing his 5th toe while climbing into his truck a week ago and now noticed two days ago that it was spreading to his other toes. As his nurse, you note that Javeed can ambulate without any gait aids and when you ask his pain score, he states it is a 5/10 in his right foot. According to Javeed, he has been a truck driver for about 40 years. He is divorced, lives alone, and has one estranged son.
When you ask Javeed about his medical history he laughs and states, “Well I’ve been here a few times, I have a bit of diabetes and high blood pressure, I take pills for that”. He is unable to recall all the medications, but he is taking them regularly. When you review Javeed’s chart, you note that his past medical history includes diabetes with diabetic neuropathy, atrial fibrillation, coronary artery disease, peripheral vascular disease, and hypertension. His last visit was three months ago. His primary issue at that time was chest pain in which investigations were found to be negative, and he was discharged with follow up appointments with the cardiologist that he missed.
As you remove Javeed’s shoes and socks, you notice a foul smell and see necrotic lesions on his right 3rd, 4th and 5th toes extending up to the dorsum of his foot. In palpating his pedal pulse, you assess that his skin is cool to touch. He has limited range of motion in his toes due to swelling but he is able to ambulate. His vital signs are: blood pressure is 90/45, heart rate is 110, respiration rate is 20, oxygen saturation is 97% on room air, and temperature is 37.9 °C.
After you complete your assessment the physician enters the room and completes his own assessment. The doctor then orders septic blood work (CBC, electrolytes, lactate, vbg, & blood cultures x 2), chest and right foot x-rays, and a 1 Liter of normal saline bolus over one hour. When the orders are complete Javeed is reassessed by the physician, he is then ordered to have ceftriaxone 1 grams IV and piperacillin-tazocin 4.5 grams IV, preoperative blood work collected and to be assessed by an orthopedic surgeon. When reviewing his results, you note that he has a white blood count of 28.9 × 109/L (with 83% neutrophils), hemoglobin A1C of 12%, random glucose level of 18.8 mmol/L, and the x-ray impression of his right foot shows acute osteomyelitis. As you collect additional blood work the surgeon enters the room, introduces herself and proceeds to explain to Javeed that he has an infection in his right foot that extends into his bone. The surgeon then states that due to the history of his uncontrolled diabetes and peripheral vascular disease she recommends he consents to having a below the knee amputation. After thoroughly explaining the procedure and its associated benefits and risks, the surgeon asks Javeed if he understands and consents to the procedure. Javeed states that while he understands, he needs to think about it before signing the consent form. When the surgeon leaves, you speak wih Javeed and discover that although he understands his diagnosis and the required treatment, he feels guilty for continuing to eat fast food meals while working. You also discover that Javeed is concerned that after the procedure he would no longer be able to work as a truck driver and financially support himself. You decide to then advocate for Javeed to be consulted to see a social worker so that Javeed can explore what assistive devices will available post-surgery as well as discuss financial supports. After meeting with the social worker Javeed feels comfortable with proceeding with the surgery and signs the consent form.