Integrated Patient Centred Management in The Care, of Complex Multimorbidity

Samenvatting

Background: This case report highlights the care of a woman in her late 40s with Type 2 Diabetes Mellitus, hypertension, and obesity, presenting with a left foot wound and pain, with a diagnosis of diabetic foot syndrome and sepsis. She was managed through Integrated Patient Centered Management and multidisciplinary and family-oriented care approach.

Case Presentation: This is a case of a 49-year-old woman with Type 2 Diabetes Mellitus, hypertension, and obesity, who presented with a left foot wound and pain. Random blood glucose at presentation was unrecordably high. A multidisciplinary team, coordinated by a Family Physician, managed her complex condition and prevented impending mortality. This care included intensive medical care, daily wound debridement, and ultimately, a left below-knee amputation due to severe sepsis and suboptimal glycemic control.

Discussion: The case highlights the critical role of a multidisciplinary approach and the Family Physician's coordination in integrating specialist care and involving the patient's family in the management of patients with complex multimorbidity. Family members provided crucial emotional and practical support, significantly aiding her recovery and rehabilitation.

Conclusion: This case underscores the importance of patient-centered, coordinated, and continuous care led by a Family Physician, with strong family integration, and multidisciplinary approach for achieving optimal outcomes in complex multimorbidity like diabetic foot syndrome.