Case Study:

Sarah Smith is a 28 y/o African American female who presents to the office with c/o wound to her left foot for the past few days. States she had tripped and fell while barefoot scraping the top of her foot on the pavement. She denies any other injury from the incident. Over the past 24 hours the wound has had “smelly” drainage. Has been experiencing generalized achiness, but denies fever and chills. Did not seek medical attention at the time of injury. Has been using hydrogen peroxide to clean her wound. Is unclear of her last tetanus vaccination. Patient PMHx significant for DM II. States that she takes her medications when she remembers, and does not always check her blood sugar.


Asthma: no hospitalizations for exacerbation.





Former tobacco user: ceased smoking 2 years ago. Had smoked 1ppd x 5 years

ETOH: socially

Illicit drugs: denies


Significant for paternal DM, otherwise unremarkable


Metformin: 500mg BID po – did not take the last few days

Albuterol MDI: 2 puffs every 6 hours prn – last use just PTA

Singulair: 10mg po daily

Trinessa: 1 tab po daily – last taken this am


PCN: hives

LNMP: 2 weeks ago.



General: denies any weight changes, fatigue or fever; + body aches

Skin: denies any rashes; + wound to left foot

HEENT: denies headache, head injury, dizziness, lightheadedness;

Denies any vision changes

Denies any hearing changes, tinnitus, vertigo, earache

Denies any nasal congestion, discharge, nose bleeds or sinus tenderness

Denies any sore throat, difficulty swallowing

Neck: denies any swollen glands, pain

Breasts: denies any pain, discharge

Respiratory: denies any dyspnea; positive cough and wheezing

CV: denies any chest pain, edema

GI: denies any nausea/vomiting/diarrhea/constipation; denies bloody stools

PV: denies claudication, swelling to LE

GU: denies frequency, urgency, burning;

Denies vaginal discharge, itching, sores

Denies penile discharge, itching or sores

MS: positive pain to left foot

Psych: denies nervousness, depression

Neuro: denies Headache, dizziness, vertigo, syncope, weakness; + numbness to right LE

Heme: denies any easy bruising

Physical Exam:

Vital signs: 100.5 (tympanic), 162/88, 118, 22, O2 sat 95% on RA

Height: 5’5” Weight: 250 lbs.

Blood glucose: 230 (Fasting; states has not eaten yet today)

patient awake, alert, oriented x 4 in NAD

Skin: warm, dry, color WNL. 4 cm lesion noted to anterior left foot with crusting and purulent drng; + surrounding erythema extending up 7 cm proximally

HEENT: head nontraumatic, normocephalic

Pupils PERRLA, EOMs intact; disc margins sharp, without hemorrhages, exudates; no AV nicking noted

Ears: bilateral TM with good cone of light and intact

Nose: mucosa pink, septum midline; no sinus tenderness appreciated

Mouth: mucosa pink, moist; tongue midline; tonsils 1+ without exudate

Neck: supple; trachea midline; no LAD

Resp: regular and unlabored; lungs with end expiratory wheezing throughout

CV: RRR, S1 and S2 noted; no s3, s4 or murmur appreciated

Abdomen: soft, non-distended; Bs + x 4; no tenderness with palpation; no CVA tenderness with percussion

Genitalia: deferred

Rectal: deferred

Extremities: warm and without edema; calves supple, non-tender

PV: no LE edema

MS: + swelling to left foot; + tenderness of 2-4th left metatarsals; + left pedal pulse; CMS intact; Cap refill < 2 sec.

Neuro: alert, cooperative; thought coherent; oriented x 4; cranial nerves II-XII intact


List your differentials for her current problems. Remember you should have at least three different differentials for each problem. Include rationale for each differential.
At this time what medical diagnoses are you most concerned about? Do they impact other diagnoses? If so, how?
What diagnostic images would you order? Provide your rationale. What are you trying to rule in or out?
What laboratory work would you order? What would you anticipate to be abnormal? Provide your rationale for each.
What is your comprehensive plan of care? Include your rationales.
Include 3-5 references with in-text citations. Must be within 5 years


Sarah Smith, a 28-year-old African American woman, has a c/o wound on her left foot. She stumbled and fell barefoot, scraping her foot on the pavement. She denies any other injuries. The wound has produced “smelly” drainage for 24 hours. Has widespread aches but no fever or chills. Didn’t seek medical attention when injured. Cleans her wound with hydrogen peroxide. Her last tetanus shot is unknown. Patient PMHx for DM II. She says she only takes her pills when she recalls and doesn’t always check her sugar.


No asthma exacerbations hospitalized.

DM 2




Former smoker: quit 2 years ago. 1ppd for 5 years


narcotics: denies


Except for paternal DM, unimpressive


Metformin: 500mg BID po – missed a couple days

Albuterol MDI: 2 puffs every 6 hours prn

Singulair: 10 mg tid

Trish: 1 tab p.o.



2 weeks LNMP.



+ bodily aches; denies weight changes, weariness, or fever.

Skin: no rashes; + left foot wound

“Headache”: “Headache”: “Headache”:

Refutes any eye alterations

Denies hearing loss, tinnitus, vertigo, or ear pain.

Denial of sinusitis or nasal congestion.

Denies painful throat or swallowing issues

Neck: no swollen glands, no pain

Breasts: no pain, no discharge

Respiratory: no dyspnea, but coughing and wheezing

CV: no chest pain or edema

GI: denies nausea/vomiting/diarrhoea/constipation/bloody stools.

PV: no claudication, no edema LE

GU: denies recurrence, urgency, or

Denies discharge, irritation, and sores

Denial of penile discharge, itching, and sores

MS: left foot pain

Psych: denies anxiety, sadness

denies numbness to right LE, headache, dizziness, vertigo, syncope

Heme: no visible bruises


tympanic), 162/88, 118, 22, O2 sat 95% on RA

5’5″ 250 lbs

230 mg/dl (Fasting; states has not eaten yet today)

OAD x 4 in NAD

Lesion 4 cm in size, anterior left foot, crusting and purulent drng; surrounding erythema 7 cm proximally

HEENT: normocephalic, nontraumatic

There were no signs of AV nicking or hemorrhaging in the pupils.

Bilateral TM with nice light cone and intact

Nose: pink mucosa, midline septum; no sinus pain

Tonsils 1+ without exudate, pink mucosa, tongue midline

Thyroid: no LAD; trachea midline

End expiratory wheeze throughout the lungs

There was no s3, s4, or murmur.

Soft, non-distended abdomen; Bs + 4; no palpable CVA discomfort; no percussion tenderness



Extremities: warm, no edema; elastic, non-tender calves

No LE edema.

CMS intact; Cap refill 2 sec.

Oriented x 4; cerebral nerves II-XII intact


List your solutions to her present issues. Remember to have three differentials for each task. Justify each disparity.
What medical diagnoses worry you now? CAN THEY AFFECT DIFFER But how?
What tests would you order? Justify your choice. What are you seeking to exclude?
What tests would you order? What do you consider abnormal? Justify your choices.
What is your overall care plan? Include reasons.
Include 3-5 in-text citations. 5 years or less