Clinical Commander

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endo.diabetes-related-foot-disease.v1

Diabetes-related foot disease (ulcer, infection, osteomyelitis)

endocrinologychronicacutesubacuteadultoutpatientinpatientacute
Start encounter →Print handoutPRODUCTION

PLANNED dossier — no manifest, package, or design brief on disk yet. IDSA 2023 severity-tiered antibiotic ladder explicitly mapped: mild (cephalexin / clinda / doxy / TMP-SMX × 1–2 wk), moderate (amox-clav OR cipro+metro × 2–4 wk), severe (pip-tazo OR carbapenem + vanco × 4–6 wk), osteomyelitis (6 wk targeted bone-penetrating). Multidisciplinary care emphasized: podiatry + wound care + endocrinology + vascular surgery; offloading via TCC gold standard; revascularization for CLTI per BEST-CLI / SVS-ESVS-SCAI; smoking cessation; A1c <8% for healing. Action plan covers daily inspection, signs of infection, footwear, offloading device, glycemic targets, and ED triggers (fever, spreading redness, gas, gangrene, acute ischemia). GAPS — no RxCUIs (validate via npm run research:rxnav:validate); no DFI-specific workup adapter in registry (uses workup.pad + standard panels); no test_files; no IDSA / WIfI / SINBAD calculator yet in registry; LOINC list partial; rifampin combination dosing and duration for biofilm-osteo simplified — production should include rifampin partner-drug stop rules.

Entry points (6)

  • symptom
    Open ulcer / wound on foot in patient with diabetes (IWGDF 2023)
    foot_ulcer_open_wound
  • symptom
    Foot redness / warmth / swelling — suspected infection (IDSA 2012 Lipsky)
    foot_redness_warmth_swelling
  • symptom
    New foot pain or loss of sensation — neuropathy or ischemia (IWGDF 2023)
    foot_pain_or_loss_of_sensation
  • imaging
    Foot X-ray findings of osteomyelitis or Charcot (IWGDF 2023)
    foot_xray_findings
  • history
    Prior diabetic foot ulcer or amputation — high-risk surveillance (IWGDF 2023)
    prior_amputation_or_ulcer
  • history
    Gangrene / necrosis of toes / forefoot (IWGDF 2023)
    gangrene_or_necrosis

Required inputs (16)

  • agerequired
    demographic • used at CONTEXT
    Age + diabetes duration drive complication burden + revascularization candidacy (IWGDF 2023)
  • diabetes_duration_typerequired
    history • used at CONTEXT
    T1 vs T2; duration informs neuropathy + vascular disease likelihood (IWGDF 2023; ADA 2026)
  • prior_dfu_or_amputationrequired
    history • used at CONTEXT
    Highest predictor of new ulcer / amputation (IWGDF 2023)
  • smoking_statusrequired
    history • used at CONTEXT
    Smoking cessation is critical for healing and vascular outcomes (IWGDF 2023; ADA 2026)
  • hba1crequired
    lab • used at INITIAL_WORKUP
    Glycemic control benchmark; A1c <8% target for ulcer healing (ADA 2026)
  • creatininerequired
    lab • used at INITIAL_WORKUP
    Renal function — antibiotic dosing, contrast for angiography, CKD stage (IWGDF 2023)
  • cbcrequired
    lab • used at INITIAL_WORKUP
    Leukocytosis suggests infection severity (often blunted in diabetes) (IDSA 2012 Lipsky)
  • crp_esrrequired
    lab • used at INITIAL_WORKUP
    CRP and ESR for infection / osteomyelitis follow-up; ESR >70 supports osteo (IDSA 2012 Lipsky)
  • wound_culturerequired
    lab • used at INITIAL_WORKUP
    Deep tissue or bone culture preferred over swab — drives antibiotic targeting (IDSA 2012 Lipsky)
  • foot_xrayrequired
    imaging • used at INITIAL_WORKUP
    First imaging — bone resorption, gas, foreign body, fracture / Charcot (IWGDF 2023)
  • mri_foot
    imaging • used at BRANCHING_WORKUP
    Best imaging for osteomyelitis vs Charcot; soft-tissue abscess (IDSA 2012 Lipsky; IWGDF 2023)
  • abi_or_tbi_or_tcpo2required
    imaging • used at INITIAL_WORKUP
    PAD assessment — ABI <0.9 PAD; <0.4 CLTI; ABI may be falsely elevated in calcified vessels — use TBI or TcPO2 (IWGDF 2023)
  • wound_size_depth_featuresrequired
    symptom • used at CONTEXT
    IWGDF / SINBAD / WIfI staging — size, depth, location, ischemia, neuropathy, infection (IWGDF 2023)
  • probe_to_bonerequired
    symptom • used at CONTEXT
    PTB positive predicts osteomyelitis (LR ~7) (IDSA 2012 Lipsky)
  • systemic_signs_of_infectionrequired
    symptom • used at RED_FLAGS
    Fever, hypotension, tachycardia, AMS = systemic; informs IDSA severity (mild / moderate / severe) (IDSA 2012 Lipsky)
  • current_meds_allergiesrequired
    medication • used at TREATMENT
    Antibiotic allergies; renal-dose adjustments; interactions (warfarin, sulfonylureas with TMP-SMX) (IDSA 2012 Lipsky)

12-phase flow (12)

  1. 1FRAME
    Assess for ulcer (with/without infection), Charcot, ischemia, neuropathy; establish chronic foot risk class (IWGDF 0–3)
    inputs: diabetes_duration_type, prior_dfu_or_amputation, wound_size_depth_features
    advance: risk class + acute pathway documented
  2. 2ENTRY
    Capture trigger: ulcer / infection / pain / imaging finding / surveillance visit
    inputs: age
    advance: trigger documented
  3. 3CONTEXT
    Diabetes status, smoking, prior ulcer/amputation, footwear, occupation, social support, comorbidities (CKD, ASCVD, neuropathy, retinopathy)
    inputs: diabetes_duration_type, prior_dfu_or_amputation, smoking_status, current_meds_allergies
    advance: context complete
  4. 4RED_FLAGS
    Sepsis, gas in tissue, rapidly spreading infection, necrotizing soft-tissue infection, CLTI with rest pain — emergent admission, broad-spectrum IV antibiotics, surgical / vascular consult
    inputs: systemic_signs_of_infection
    actions: workup.aki
    advance: limb / life threats stabilized
  5. 5INITIAL_WORKUP
    CBC, CMP, CRP, ESR, A1c, wound culture (deep), foot X-ray (bilateral), ABI / TBI / TcPO2, probe-to-bone test, classification (IDSA severity, IWGDF SINBAD, WIfI ischemia/wound/foot infection)
    inputs: hba1c, creatinine, cbc, crp_esr, wound_culture, foot_xray, abi_or_tbi_or_tcpo2, probe_to_bone
    actions: panel.cbc, panel.renal, panel.inflammation, panel.glucose_a1c
    advance: severity + ischemia + infection class assigned
  6. 6BRANCHING_WORKUP
    MRI foot if osteomyelitis suspected; bone biopsy gold standard; angiography (CTA / MRA / DSA) for revascularization candidates; nuclear imaging only if MRI contraindicated
    advance: osteomyelitis confirmed/ruled out and PAD anatomy defined
  7. 7DIFFERENTIAL
    Phenotype: neuropathic ulcer, ischemic ulcer, neuro-ischemic, Charcot foot, gas-forming infection, necrotizing fasciitis, abscess, osteomyelitis, gangrene
    advance: phenotype assigned
  8. 8RISK_STRATIFICATION
    IDSA infection severity (mild / moderate / severe), IWGDF SINBAD, WIfI staging for amputation risk + benefit of revascularization
    inputs: wound_size_depth_features, systemic_signs_of_infection
    actions: calc.ckd_epi_2021
    advance: staged
  9. 9TREATMENT
    Multidisciplinary: empiric abx by IDSA severity (mild oral 1–2 wk; moderate 2–4 wk PO/IV; severe IV 4–6 wk; osteomyelitis 6 wk targeted); revascularization for PAD with non-healing or CLTI; offloading (TCC gold standard for plantar neuropathic); glycemic control A1c <8%; smoking cessation; podiatry; wound care (debridement, dressings); negative-pressure wound therapy (NPWT) for selected wounds; HBO selective per IWGDF
    inputs: hba1c, creatinine, wound_culture, abi_or_tbi_or_tcpo2
    advance: plan in motion across all axes
  10. 10DISPOSITION
    Outpatient for IDSA-mild + good vascular supply + reliable patient; admit for IDSA-moderate-severe + IV antibiotics + surgical debridement + revascularization planning; ICU if septic / NSTI / unstable
    advance: level of care assigned
  11. 11MONITORING
    Wound size + depth weekly; CRP/ESR every 1–2 wk during osteo treatment (expect ≥50% reduction by 4 wk); A1c at follow-up; weight-bearing audit; offloading adherence
    inputs: crp_esr, hba1c
    advance: healing trajectory acceptable
  12. 12FOLLOWUP
    Multidisciplinary clinic q1–4 wk; podiatry + wound care + endocrinology + vascular; preventive education (daily inspection, footwear, hygiene); annual screening (monofilament, ABI/TBI, foot exam); secondary prevention after healed ulcer
    advance: long-term care plan documented