What is the best course of treatment for a 47-year-old female patient with a history of poorly controlled diabetes mellitus, bipolar disorder, hyperlipidemia, and gastroesophageal reflux disease (GERD), who presents with severe right foot and knee pain, and a possible fungal infection on her back, after being diagnosed with a right foot fracture and treated with a walking boot and ibuprofen (IBU)?

From the Guidelines

The best course of treatment for this 47-year-old female patient requires a comprehensive approach addressing multiple conditions, prioritizing her poorly controlled diabetes, right foot fracture, and possible fungal infection.

Key Considerations

• Her right foot fracture should be managed with continued use of the walking boot, but ibuprofen should be replaced with acetaminophen (500-1000mg every 6 hours as needed) to avoid potential complications with her diabetes, as suggested by recent clinical guidelines 1.
• Her poorly controlled diabetes requires immediate attention with endocrinology consultation, optimization of insulin therapy or oral hypoglycemic agents, and regular blood glucose monitoring, given the high risk of foot complications and infections in diabetic patients 1.
• For the possible fungal infection, topical antifungal treatment such as clotrimazole or terbinafine cream applied twice daily for 2-4 weeks is recommended, with dermatology referral if no improvement occurs, in line with standard treatment protocols for fungal infections.
• Her bipolar disorder medication should be reviewed to ensure compliance and efficacy, while her hyperlipidemia may require statin therapy adjustment based on recent lipid panels, considering the potential interactions between these medications and her diabetes treatment.
• For GERD management, a proton pump inhibitor like omeprazole 20mg daily before breakfast should be continued or initiated, as part of a comprehensive approach to managing her multiple conditions.

Foot Care and Education

• The patient needs comprehensive foot care education, including daily inspection for wounds, proper hygiene, and wearing appropriate footwear, to prevent further complications and promote healing, as emphasized in guidelines for the prevention of foot ulcers in persons with diabetes 1.
• Given her high risk of foot ulceration, regular screening for signs of peripheral neuropathy and peripheral artery disease (PAD) is crucial, along with prompt treatment of any pre-ulcerative lesions or excess callus on the foot, to help prevent a foot ulcer 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Carefully consider the potential benefits and risks of ibuprofen tablets and other treatment options before deciding to use ibuprofen tablets. Mild to moderate pain: 400 mg every 4 to 6 hours as necessary for relief of pain.

The patient is currently taking ibuprofen (IBU) for severe right foot and knee pain, which is reported to help. However, the patient's dosage is not specified. Key Considerations:

• The patient has a complex medical history, including poorly controlled diabetes mellitus, bipolar disorder, hyperlipidemia, and GERD.
• The patient has been diagnosed with a right foot fracture and was instructed to wear a walking boot for 6 weeks.
• The patient reports increased pain when wearing the boot and has not been wearing it as instructed.
• The patient is experiencing severe right foot and knee pain, with a pain level of 10/10.
• The patient is also concerned about a possible fungal infection on her back.

Recommendations:

• The patient should continue taking ibuprofen as needed for pain relief, with a maximum daily dose of 3200 mg.
• The patient should be monitored for signs of gastrointestinal bleeding, as well as other potential side effects of ibuprofen.
• The patient's diabetes, bipolar disorder, hyperlipidemia, and GERD should be considered when managing her pain and other symptoms.
• The patient should be referred to a specialist for further evaluation and management of her right foot fracture and possible fungal infection.
• The patient should be educated on the importance of wearing the walking boot as instructed to promote proper healing of the fracture. 2 2 2

From the Research

History of Present Illness (HPI)

The patient is a 47-year-old female with a complex medical history, including poorly controlled diabetes mellitus, bipolar disorder, hyperlipidemia, and gastroesophageal reflux disease (GERD). She presents with severe right foot and knee pain, which she rates as 10/10, and denies numbness and tingling. The pain is worse with activity.

Chief Complaint

The patient's chief complaint is right foot pain, which was diagnosed as a fracture in the ER on 5/27/25. She was instructed to wear a walking boot for 6 weeks but has not been wearing it due to increased pain.

Current Symptoms

• Severe right foot and knee pain (10/10)
• Pain worsens with activity
• Denies numbness and tingling
• Taking ibuprofen (IBU) for pain, which provides some relief

Additional Concerns

• Possible fungal infection on her back, characterized by dark spots
• Previous concern about bed bugs due to her living situation, but no longer experiencing itching, pain, or open wounds

Relevant Studies

• A study on digital tools for obtaining the HPI found that these tools can improve the efficiency and quality of care 3.
• Another study on reorganizing the HPI to improve verbal case presenting and clinical diagnostic reasoning skills found that a thorough HPI is essential for accurate diagnosis 4.
• A study on fungal infections found that they can have debilitating effects on a person's quality of life and may be more common in immunocompromised individuals 5.
• A study on the therapeutic potential of the HPI found that it can help patients make cognitive sense of their illness and serve as a vehicle for sharing the affective burden with the physician 6.
• A study comparing computer-generated vs. physician-documented HPIs found that computer-generated HPIs were of higher overall quality and more useful for clinicians 7.