Diabetic Foot Osteomyelitis + Suspected PE

S — Subjective

53-year-old female with a known 12-year history of diabetes. Presented with a non-healing ulcer on her right foot present for approximately one month. Primary acute complaint is new-onset shortness of breath (dyspnea) requiring supplemental oxygen.

O — Objective

• SpO₂: 95% on 3 L/hr O₂ via nasal cannula | HR: 100 bpm | BP: 115/66 mmHg
• Right great toe: Non-healing ulcer with surrounding abscess; deep infection confirmed as osteomyelitis on imaging
• Left foot: Bandaged (baseline foot disease)
• Chest X-Ray: Clear — no infiltrates, no effusion, no pulmonary oedema
• Venous Doppler (right lower limb): No DVT; confirmed abscess with likely osteomyelitis of distal phalanx, right great toe
• Random blood glucose: Extreme variability — 108 to 514 mg/dL
• D-dimer: Elevated — in the thousands (⚠ See EBM critique — non-interpretable in osteomyelitis context)
• Renal function (eGFR): GAP Not yet checked — critical for LMWH dosing
• Patient values / consent: GAP Not documented in SOAP note

A — Assessment

• Acute Hypoxic Respiratory Failure: Working diagnosis — Pulmonary Embolism (PE). Basis: acute hypoxia + clear CXR + elevated D-dimer. DVT not identified on right lower limb Doppler (clot may have embolized or originated elsewhere).
• Uncontrolled Diabetes Mellitus (T2DM): Infected Diabetic Foot Ulcer with confirmed osteomyelitis (likely source of hypercoagulable state). Severe glycemic variability (108–514 mg/dL) — failing insulin regimen.

P — Plan

• PE: Start LMWH (Enoxaparin 1 mg/kg q12h) after checking renal function. Arrange STAT CTPA to confirm diagnosis. Supplemental O₂ to maintain SpO₂ >94%.
• Infection/Sepsis: Urgent surgical/orthopaedic consult for debridement. Broad-spectrum IV antibiotics with bone penetration.
• Diabetes: Convert to basal-bolus insulin from sliding scale. Consider endocrinology consult.