CASE PRESENTATION

A. PATIENT INDETITY
Name : Ms. S
Age : 48 Years Old
Sex : Female
Address : Bojon kulon
Religion : Moslem
Marital Status : Married

B. ANAMNESIS
1. Main Grievance
Pain on the right foot
2. Historical of Present Disease
1.5 months before admission the patient complained of arose wound in
his right leg. Initially the wound is only a small hole in the web spaces of the
little finger, for long wound into larger, deeper, swell and fester. Patients did
not complain of pain in the wound. Patients admitted to the foot is not
affected by blunt and sharp stuff before, everyday patient wearing socks.
Patients try to treat the wound with betadine but the wound did not heal.
Previously patients often feel a tingling in his legs.
10 days before admission the patient complained of stomach nausea,
fatigue, stomach ached and burned mainly in the gut that felt a little better
after eating. Patients also felt the body was shivering.
10 years ago patients complain of frequent thirst, constant hunger and
frequent urination, and patients also complained of her weight continued to
decline, then the patient went to the hospital Arjawinangun, and it is said
that the patient has diabetes and is recommended to regularly take
medicine.
When admitted to hospital patient check-up in the polls, the patient
complained of foot ulcers do not heal since 1.5 months ago. Patients also
complain of stomach ache in the pit of the stomach, nausea and increasingly
limp body. Patients ate little, no vomiting, bowel and bladder no
abnormalities. Patients admitted to the body still shivering. Then the patient
is advised by physicians for inpatient and do cleaning wounds.
 3. Historical of Past Disease
a) Diabetes Melitus (+)
b) Hipertension (-)
c) Heart Disease (-)

4. Historical of Family Disease

a) Hipertension (-)
b) Diabetes Melitus (+)

C. MEDICAL EXAMINATION
Vital Sign
Generan Condition : Moderate
Awareness : Compos mentis
Blood Pressure : 130/80 mmHg
Pulse : 90 x/m
Breathing : 25 x/m
Temperature : 37,8 C

General Status
Head
a) Form : Normochepal
b) Hair : Black colour, No hair fall
c) Eye : Conjungtival Pallor -/-, Icteric Sclera -/-, Light reflect (+), Isocor Pupil
d) Ear : Normotia, Cerumen (-/-), Tympanic Membrane Intact
e) Nose : Normal form, Deviation (-), Secret (-)
f) Mouth : Normal

Neck
a) Enlargement of lymph nodes (-)
b) Tachea in the middle
c) No mass

Thorax
a) Lungs Pulmonary
Inspection : The right and left of his chest shape is symmetrical
Palpation : His right and left fremitus tactile and vocal is symmetrical,
crepitus (-), tenderness (-), rebound tenderness (-)
 Percussion : The sound of percussion are resonant in both of his lung fields
Auscultation : The sound of his lung is vecular and bronchial in the entire of
lung field, ronkhi -/-, wheezing -/-

b) Heart
Inspection : Ictus cordis is visible, about 2 finger below left papilla mammae
Palpation : Ictus cordis palpable on the left of midclavicula on ICS line 5
Percussion : Upper limit ICS 3 linea parasternalis sinistra
Right limit ICS 4 linea sternalis dextra
Left limit ICS 5 linea midclavicula sinistra
Auscultation: Heart sound I-II pure regular, murmur (-), gallops (-)

c) Abdomen
Inspection : Flat abdomen shape, supple, skin disorder (-)
Auscultation : Bowel (+) normal
Percussion : Thymphanic abdomen
Palpation : Tenderness (-), Rebound tenderness (-)

d) Ekstremity
Superior : Warm acral, edema -/-, CRT <2 sec
Inferior : Warm acral, edema -/-, CRT <2 sec, Ulcus (Right Foot)

D. IVESTIGATIONS
a) Complete Blood
Hameoglobin : 11,1g/dl
Leukosit : 20,21 ul
Haematicrit : 34,0 %
Platelet : 381.000 ul
b) Ureum : 19,2 mg/dl
c) Creatinin : 0,60 mg/dl
d) Blood Sugar : 344 mg/dl

E. DIAGNOSIS OF WORK
Diabetic Ulcus

F. DIFFERENTIAL DIAGNOSIS
Chronic Venous Insuficiency
G. MANAGEMENT PLANT
Planning Therapy :
Non Medical : Observation of vital sign
Patient and family education about this diseases

Medical : Cefazolin 2x1

Ketorolac 2x1
Ranitidine 2x1
Antrain 3x1
Novorapid 3x10 U

Operation : Debridement

H. PROGNOSIS
Quo ad vitam : Ad Bonam
Quo ad functionam : Dubia Ad Bonam
Quo ad sanationam : Dubia Ad Bonam

Literature Review
Diabetic Ulcers
The ulcers are open sores on the skin or mucous membranes accompanied by
extensive tissue death and invasive saprophyte germs. Diabetic ulcers are one of the
chronic complications of diabetes such as open sores on the skin surface which can be
accompanied by local tissue death.
In patients with diabetic ulcers due to microangiopathic also called hot gangrene
because although necrosis, akral area was red and feel warm by inflammation, and
usually palpable distal arterial pulsation. Diabetic ulcers are usually found on the soles
of the feet. Makroangiopati process causes blockage of blood vessels makroangiopati
process causes blockage of blood vessels that will provide clinical symptoms 5 P,
namely (3):
1) Pain (pain).
2) Paleness (pallor)
3) Paresthesia (paraesthesia and tingling).
4) Pulselessness (pulse missing).
5) Paralysis (lame).
According to the severity of lesions, abnormalities of diabetic ulcers are divided
into six degrees according to Wagner, that :
1. Degree 0: no open lesions, skin still intact with the possibility of foot deformity
accompanied by a "claw, callus"
2. Grade I: superficial ulcers confined to the skin
3. Degree II: ulcers, tendon or bone penetrating
4. Grade III: abscess in with or without osteomilitas
5. Degree IV: ulcers on the toes or the distal part of the foot or without selulitas
6. The degree V: gangrene whole leg or part of leg

Pathophysiology of diabetic ulcers

Vascular disorders in diabetic patients is one of the causes of diabetic ulcers. In
ischemic vascular disorders occur. The condition, in addition to being the cause of
ulcers also complicates the process of healing leg ulcers and facilitate the emergence of
infection. Ischemia is a condition caused by lack of blood in the tissue so that the
oxygen deficiency. The disorder occurs through two processes, namely:

1. Makroangiopati
Makroangiopati are known to be narrowing and blockage of blood vessels and
large-size causing ischemia and ulcers. With the DM sterosklerosis process is
rapid and more severe with the involvement of multiple blood pembuuh.
 Atherosclerosis is usually proximal but is often associated with arterial occlusion
distal to the knee, especially the posterior and anterior tibial artery, peronealis,
metatarsalis, as well as digitalis arteries.
2. Mikroangiopati.
Mikroangiopati a narrowing and blockage of peripheral blood vessels, often
occurs in the lower limbs, especially legs, as a result of tissue perfusion distal
part of the legs is reduced and then raised diabetic foot ulcers. Microangiopathy
process makes blood circulation decreased tissue characterized by missing or
reduced pulse in the dorsalis pedis artery, tibial and popliteal, feet become cold,
atrophy and thickened nails. The disorder occurs subsequent tissue necrosis
causing ulcers that usually starts from the foot or leg.
In addition to the above process in DM patients increased HbA1c erythrocytes
caused deformability of erythrocytes and the release of oxygen in tissues by
erythrocytes disrupted, resulting in blockages that interfere with tissue
circulation and lack of oxygen resulting in tissue death that subsequently arise
ulcers. Increased levels of fibrinogen and platelet activity levels resulted in a
high red blood cell aggregation so that blood circulation becomes sluggish and
facilitate the formation of platelets in the blood vessel wall which would
interfere with blood circulation.
Pathophysiology at the biomolecular level to cause peripheral neuropathy,
peripheral vascular disease and a decrease in immune system that result in
disruption of wound healing process. Peripheral neuropathy in diabetes mellitus
disease can cause damage to the motor fibers, sensory and autonomic. Damage
to motor fibers can cause muscle weakness, muscle atrophy, deformities
(hammer toes, claw toes, pes cavus, pes planus, halgus valgus, Achilles tendon
contracture) and together with their ease neuropathy callus formation. Damage
to sensory fibers that occur due to damage to the myelin fibers resulting in
decreased sensation of pain so as to facilitate the occurrence of foot ulcers. In
addition to the hyperglycemia occurs defect in cell metabolism so that the
conduction implus Schwan disturbed. Legs do not feel it would be dangerous
because when stepping on sharp objects will not be felt when it had been
incurred injuries, coupled with the ease of infection. Damage caused by
autonomic fibers sympathetic denervation cause dry skin (anhidrosis) and the
formation of fissures of the skin and leg edema.

The process of formation of ulcers

Figure IV. The process of formation of ulcers (11)

Diabetic ulcers consists of a central cavity is typically larger than the entrance,
surrounded by a hard and thick callus. The formation of ulcers associated with
hyperglycaemia that affects the peripheral nerves, collagen, keratin and vascular supply.
With the mechanical stress formed keratin hard on the toe area experiencing the greatest
burden. Peripheral sensory neuropathy allow repetitive trauma resulting in damage to
the tissue beneath the callus area. Further formed cavity enlarges and eventually
ruptures to the skin surface causing ulcers. Ischemia and abnormal wound healing
manghalangi resolution. Microorganism enters hold the colonization of this area. Sugar
levels, elevated blood makes a bacterial growth coupled with disturbances in the
immune function so that the bacteria are difficult to clean and the infection spread to the
surrounding tissues.

DIAGNOSIS
A. History / SYMPTOMS CLINICS
Anamnesa conducted an initial stage of collecting the necessary data in mengevaluai
and identify a disease. In anamnesis is very important is to know whether the patient has
a history of diabetes for a long time. The symptoms of diabetic neuropathic are often
found is frequently tingling, burning sensation in the feet, cramps, body aches all,
especially at night. Symptoms of neuropathy causing a loss or reduction of pain the legs,
so that if the patient got the trauma will be little or no pain so getting foot ulcers.
It was also necessary to know whether there is a blood vessel disorder by asking leg
pain after walking a certain distance due to blood flow ketungkai reduced (intermittent
claudication), fingertip feel cold, pain in the night, arterial pulse disappeared, the foot
becomes pale when raised and if wounds that are difficult to heal.
B. PHYSICAL EXAMINATION
1) Inspection
the inspection will appear dry skin and cracked due to reduced production of sweat. This
is due to denervation of the skin's structure. There are also hair loss foot or toes, nail
thickening, the callus in areas of emphasis such as the heel, plantar aspect of the
metatarsal head. In the form of claw toe deformity often on the thumb. In areas of
emphasis is a diabetic ulcer location because of repeated trauma with no or little felt by
the patient. Forms need to be described as ulcers; edge, smelly, basic, no or no pus,
exudates, edema, callus, ulcer depth.

Figure V. Examination of the inspection and palpation.

2) Palpation
Dry skin and chapped easily distinguished from healthy skin. Palpability artery
occlusion will cause the cold and the loss of pulsation in the artery involved. Callus
around the ulcer will be felt as the area is thick and hard. Description ulcer should be
clear because it affects the prognosis as well as the actions to be taken. If the pus does
not seem the emphasis on the area around the ulcer is very important to determine
whether there is pus. Exploration is done to see the extent of the cavity and
subcutaneous tissue, muscle, tendon and bone involved.

3) Sensory Examination
In patients with DM usually neuropathy damage has occurred before tebentuknya ulcer.
Therefore, when the inspections have not looked their existing ulcer but sensory
neuropathy, the process of formation of ulcers can be prevented. The trick is to use 10
gauge nylon monofilament. Test the monofilament is an examination of a very simple
and sensitive enough to diagnose patients who have a risk of ulcers due to have
impaired peripheral sensory neuropathy. The test results said to be normal if the patient
can not feel the touch of nylon monofilament. Sections were examined monofilament is
on the plantar side (metatarsal area, and between the heel and metatarsal and heel) and
the dorsal side.

4) Inspection of Vascular
Besides the symptoms and signs of vascular abnormalities, need to be examined with a
noninvasive vascular tests that include transcutaneous oxygen pungukuran, ankle-
brachial index (ABI), and absolute toe systolic pressure. ABI is obtained by dividing the
systolic pressure systolic pressure sleeve shank premises. If the abnormal figures
obtained should be suspected ischemia. Arteriografi needs to be done to ensure the
occurrence of arterial occlusion (16)

Figure VI. The sensory examination (15)

5) Radiological examination
Radiological examination will be able to know whether the gas obtained subcutaneous,
foreign objects and the presence of osteomyelitis.

6) Laboratory Tests
Routine blood tests showed increased leukocyte infection when it occurs. Fasting
plasma glucose and 2-hour PP should be checked to determine the level of glucose in
fat. Albumin is checked to determine a patient's nutritional status.

DIFERENTIAL DIAGNOSIS
1. Ulcers Tropikum
Tropikum ulcers are ulcers that is fast developing and pain, usually in the lower limbs.
At ulcer tropikum there are several factors that influence the occurrence of ulcers.
Among others, the trauma, the lack of hygiene, malnutrition and infection by Bacillus
fusiform. At the slightest trauma greatly facilitate the entry of germs especially with less
nutritional status so small wounds caused by trauma that can develop into an ulcer.
Usually starts with a small wound, then formed papules that quickly deteriorated into
vesicles. Vesicles then rupture and forming small ulcers. After ulcers infected by the
bacteria, ulcer extends to the side and into and give the typical form ulcers tropikum.

2. Ulcers Varikosum
Varikosum ulcers are ulcers caused due to the disruption of blood flow in the leg veins.
Disorders of the venous flow can be caused by abnormalities in the blood vessels such
as veins and dams abnormalities in the veins in the proximal lower limbs. Predileksi
area which is the area between the malleolus and calf, but tends to arise around the
medial malleolus. May also extend to the upper limbs. Often occurs varicose veins in
the lower limbs. Ulcers that has lasted for years can change the edge of the ulcer grows
raised, and bumpy. A typical sign of the extremities with chronic venous insufficiency
edema. Patients often complain of swelling in legs increased when standing and silent,
and will be reduced if done the elevation of the leg. Ulcers usually has an irregular
edges, were mixed in size, and can be extensive. At the base of the ulcer visible
granulation tissue or fibrous materials. Exudate can also be seen that a lot. Surrounding
skin looked red-brown due to hemosiderin.

MANAGEMENT AND THERAPY

The management of patients with DM ulcer is controlling blood sugar levels and
handling ulcer comprehensive DM.

1) CONTROL DIABETES
a) Non-pharmacological therapy:
The initial step treatment of patients with diabetic foot is to perform the medical
management of the disease systemically diabetes. Diabetes mellitus if not managed
properly will be able to cause a variety of chronic complications of diabetes, one of
which is the occurrence of diabetic gangrene (3). If blood glucose levels can always be
controlled properly, it is expected all the complications that will occur can be prevented,
at least inhibited. In managing diabetes mellitus steps that must be done is a non
pharmacological management, lifestyle changes, by making dietary adjustments, known
as medical nutrition therapy and increasing physical activity berupaolah mild exercise.
Planning meals in people with diabetes mellitus is also a primary treatment in the
management of diabetes mellitus. Planning meals that meet the standards for diabetes
generally based on two factors, namely; a). High-carbohydrate, low-fat, high-fiber, or
b). High-carbohydrate, high in unsaturated fatty acids single bound. Educating the
family will also greatly affect the patient's condition. The role of the family itself is
controlling food intake, medications sugar consumed each day and prevent as much as
possible so that patients do not experience injuries that can lead to infection (4).
b) Pharmacological therapy
Pharmacologic therapy is in principle granted if the application of non-pharmacologic
therapy that has been done can not control blood glucose levels, as expected.
Pharmacological therapy is given is the gift of oral anti-diabetic drugs and insulin
injections. There are six classes of oral anti-diabetic drugs are :
1) Class sulfonylureas
2) Glinid
3) Thiazolidinediones
4) -glucosidase inhibitors
5) biguanide
6) Drug-drug combination of class-golangan above

2). HANDLING diabetic ulcers

Handling on diabetic ulcers done comprehensively. Wound management is one therapy
that is very important and can have a big impact in healing wounds and prevention of
further infections. Wound management in diabetic ulcers can be through several ways:
eliminating or reducing the load pressure (offloading), keeping the wound to keep it
moist (moist), handling the infection, debridement, and skin graft revascularization.
a) Debridement
Debridement action is one important therapy in cases of diabetic ulcers. Debridement
can be defined as the removal of foreign bodies and the efforts of necrotic tissue in the
wound. The wound will not heal if they obtained necrotic tissue, debris, calus, fistula or
a cavity which allows germs thrive. After debridement of the wound should be irrigated
with saline or other cleaners and do dressing (compress). The purpose of the surgical
debridement is :
Evacuate bacterial contamination
Lifting the necrotic tissue that can speed healing
Eliminate the callus tissue
Reduce the risk of local infection
Reducing the burden of pressure (off loading)
There are several options in the debridement action, namely
mechanical debridement, enzymatic, autolytic, biologic. Mechanical debridement
performed using fisiolofis wound irrigation fluid, ultrasonic lasers, and so on, in order to
clear necrotic tissue. Enzymatic debridement performed by administering exogenous
enzyme topically to the surface of the lesion. The enzymes will destroy residual protein
residue. Autolytic debridement occurs naturally when a person is exposed to injury. This
process involves the macrophages and endogenous proteolytic enzymes that naturally
will lyse necrotic tissue. Synthetic preparations of the hydrogel and hydrocolloid can
create optimal environmental conditions for the phagocytes of the body and acts as an
agent that lyse necrotic tissue and promotes the granulation process. Eliminating or
reducing the load pressure (offloading).

b) Wound Care
Modern wound care methods emphasize moist wound healing or keep the wound moist
in a state of. Moisture balanced wound environment that facilitates cell growth and
proliferation of non-cellular matrix collagen in a healthy mouth. Luka will be quickly
cured when exudate can be controlled, keeping the wound when moist, not sticky
substance wound compresses, protected from infection and permeable to gas.Tindakan
dressing is one important component in accelerating healing of the lesion. The principle
of dressing is to create an atmosphere in a moist state so as to minimize the risk of
trauma and surgery. There are several factors to consider in choosing a dressing that will
be used, the type of ulcer, the presence or absence of exudate, presence or absence of
infection, skin conditions around and fees. There are several types of dressings that are
often used in the treatment of wounds, such as hydrocolloid, hydrogel, calcium alginate,
foam, anti-microbial compress.

c) Infection Control
Antibitoka Award is based on culture results germs. In severe infection antibitoika
Award given for 2 weeks or more. In some studies say that the dominant bacterial
infections including diabetic ulcers is then followed by streotococcus S. aureus,
coagulase-negative staphylococci, Enterococcus, Corynebacterium and Pseudomonas.
In mild or moderate diabetic ulcer antibiotics given focused on gram-positive pathogens.
In infected ulcers are more severe polymicrobial bacteria (gram-positive bacteria
include shaped cocci, rod-shaped gram-negative, and anaerobic bacteria) antibiotics
should be broadspektrum, given by injection.
d) Skin Graft
Figure VII. Skin graft (18)
An act of closing the wound where the skin removed from the donor site and transferred
to the location of the recipient. There are two kinds namely full thickness skin graft and
split thickness. Skin graft is one way of reconstruction of the skin defect, which is
caused by many things. The purpose of skin graft used in the reconstruction after
surgical removal of skin malignancy, accelerate wound healing, prevent contractures,
reducing the duration of treatment, repair defects resulting from excision of skin tumors,
sealed off the area of skin peeled off and closing the wound where the surrounding skin
is not quite cover it. Besides skin graft is also used to close chronic skin ulcers and
difficult to heal. There are three phases of a skin graft that is: imbibition, inosculation,
and revascularization. In phase imbibition process occurs absorption of nutrients into the
graft that will become a source of nutrients to the graft submarine first 24-48 hours. The
second phase is inosculation which is the process by which blood vessels donor and
recipient are related. During this second phase, sticking to tissue graft recipient with the
deposition of fibrous surface. In the third phase, namely revascularization occurred
differentiation of blood vessels in the arterioles and venules.
e) Actions Amputation
Amputation done if found the existence of gas gangrene, infected tissue, to stop the
expansion of the infection, lifting the legs are experiencing recurrent ulcers. Severe
complications from foot infections in diabetic patients is nekrotika fasciitis and gas
gangrene. In such circumstances required emergency surgery such as amputations.
Amputation aims to eliminate pathological conditions that interfere with the function,
cause disability or eliminate the causes of acquired (9).

Treatment of diabetic ulcers can be done in several levels according to the division by
Wanger, namely (6):
a) Level 0:
Handling includes educating the patient about the special footwear and complementary
footwear are recommended. Shoes or sandals that are made specifically to reduce the
pressure. When the legs are bony or deformity, usually can not be solved only by the
user's footwear generally require artificial bone protruding cutting measures
(exostectomy) or with deformity correction.
b) Level I
Require debridement of necrotic tissue or tissue that is infectious, local treatment of
wounds and reduction of the burden.
c) Level II:
Require debridement, antibiotics according to the culture results, local wound care and
burden reduction technique that is more meaningful.
d) Level III:
Require debridement of tissue has become gangrenous, amputation part, more stringent
immobilization and parenteral antibiotics according to the culture.
e) Level IV:
At this stage usually requires amputation of part or whole leg amputation.

3). EVALUATION diabetic ulcers

The basic principle of good pengeolaan against diabetic ulcers are:
a) Evaluation of the clinical state of the wound, it wounds, radiological picture (foreign
objects, osteomyelitis, their gas subcutaneous), location, biopsy vascularization (non-
invasive).
Treatment of ulcers is strongly influenced by the degree and depth of ulcers. Be careful
when encountering ulcer seems small and shallow because sometimes it is just the tip of
the iceberg and on a thorough examination of the penetration may reach the deeper
tissues.
b) Management of diabetic neuropathy
Basically, the management of diabetic neuropathy is done by controlling blood sugar
and medication causal and symptomatic. Controlling blood sugar constantly and
intensive treatment of diabetes which will inhibit progresitifitas neuropathy by 60%.
c) Metabolic Control
The occurrence of atherosclerosis is due to metabolic defects and physical defects. The
risk factors for atherosclerosis include hyperglycemia, hyperinsulinemia, dyslipidemia,
hypertension, obesity, hypercoagulability, genetic, and smoking. All of the risk factors
that can be treated should immediately be controlled as well as possible to inhibit the
process of atherosclerosis more.
d) debridement and dressing
Basically the same diabetic ulcer therapy with other therapies, that is to prepare the
wound bed is better to support the growth of granulation tissue, so that the wound
healing process can occur. We knew the wound bed preparation. It must be recognized
that no topical medications that can replace good debridement with the right techniques
and the wound healing process always begins with a clean tissue. The basic goal of
debridement is to reduce contamination on the wound to control and prevent infections.
Culture examination is necessary, especially in deep ulcers and tissue taken from the
inside. Optimal debridement is required to appear healthy tissues by removing necrotic
tissue. Debridement is not optimal will inhibit ulcer healing.
Wrapping is useful for maintaining and protecting tissue moisture, stimulating wound
healing, protects it from the outside temperature, as well as easy to open without the
pain and damage the wound. Humid atmosphere make optimal atmosphere for
accelerated healing and stimulate tissue growth.
e) Cultures
To identify the infecting bacteria culture is required. Decision swab culture material in a
way not recommended. Results of culture will be more believable if the retrieval of
materials by means of curettage of the results of the ulcer after debridement.
f) Antibiotics
In diabetic ulcer mild / moderate antibiotic that is focused on the gram-positive
pathogens. In more severe ulcers are polymicrobial infection. Antibiotics should be
broadspectrum and is given by injection.
g) Improved circulation
DM patients have a tendency to be more prone than non-DM coagulation due to a
disturbance in the plasma viscosity, erythrocyte deformibilitas, platelet aggregation as
well as an increase in Trogen and Willbrand factor. Drugs that have the effect of
reologik bencyclame, pentoxyfilin can improve erythrocyte besides reducing platelet
aggregation erythrocytes.
h) Non-weight bearing
This action is necessary because the patient's feet are generally insensitive to pain, so if
used to walk it will cause injuries grew large and deep, the best way to achieve this by
using a cast.
i) Nutrition
Nutritional factors are among the factors that play a role in wound healing. The presence
of anemia and hypoalbuminemia will greatly affect the healing process. Necessary to
monitor blood levels of hemoglobin and albumin least once a week. Iron, vitamin B12,
folic acid helps blood cells carry oxygen to tissues. Iron is also a cofactor in the
synthesis of collagen, while vitamin C and zinc is important for tissue repair. Zinc also
plays a role in the immune response.

4). Complications Diabetic Ulcers

Infection is a major threat of amputation in patients with diabetic ulcers. Superficial skin
infection if not promptly treated can penetrate the subcutaneous tissue, such as tendons,
joints, and bones or even become a systemic infection. At the infected leg ulcers and
diabetic foot infection (without ulcer) should do culture and sensitivity of germs. Nearly
two thirds of patients with foot ulcers diabteik give complications osteomyelitis.
Osteomyelitis undetected would complicate healing of the ulcer. Gulah ulcer patient's
blood could also be an obstacle in the process of wound healing and therefore should
also be consulted to the nutritionist, and if necessary, consult a physiotherapist in order
to maximize the healing process.
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