MEDICINE CASE DISCUSSION
This is an E-log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence-based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable comments in comment box are most welcomed .
I have been given this case, in an attempt to solve and understand the topic of "Patient's clinical data analysis”. This has helped me develop my competency in reading and comprehending clinical data including history taking, clinical findings and investigations. The goal is to come up with a diagnosis and treatment plan.
JATIN SHARMA
ROLL NUMBER - 46
10TH JAN 2022
CASE DISCUSSION
A 58year old male patient who is a farmer by occupation and a resident of nalgonda came to the medicine opd on 5/1/2022
CHIEF COMPLAINS:
Wound over the left foot since 5 days.
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 5 days back then he had a burn injury which resulted in the formation of blebs which ruptured and became a ulcer over dorsal aspect of left foot which was sudden in onset and gradually progressive in nature.
The size of the ulcer was about 1cm then it increased to 6cm. It is associated with pain which is present continuosly and increases on walking.
He went to the local hospital where he was given some tablets and ointment but the ulcer did not reduce.
History of serous discharge present which was foul smelling and not blood stained, reduced on medication.
No history of fever,nausea, vomiting.
No history of swelling of the leg
No history of weakness of lower limb, confusion, altered sensorium.
PAST HISTORY:
He was diagnosed with diabetes 15 years ago since then he is on oral hypoglycemic drugs for intial 5 yrs. Then changed to regular medication-inj MIXTARD due to poor glycemic control.
Similar history of ulcer present on the right foot 3 months back which was due to a trauma injury and then was treated with regular dressing and antibiotics.
No history of hypertension ,epilepsy, asthma.
No history of any past surgery.
PERSONAL HISTORY:
Diet-mixed
Appetite- normal
Sleep-adequate
Bowel and bladder-regular
Addictions- chronic alcoholic since last 20 years, Toddy everyday 2 bottles since 20 years
No allergies
FAMILY HISTORY:
No similar complains in the family
GENERAL EXAMINATION:
The patient is consious, coherent and cooperative, well oriented to time, place and person.
moderately build and well nourished.
Consent is obtained.
He is sitting comfortably on the bed.
Pallor- absent
Icterus-absent
clubbing-absent
cyanosis-absent
lymphadenopathy-absent
edema-absent
VITALS:
Temperature-Afebrile
Heart rate- 78bpm
Respiratory rate-14cpm
Blood pressure- 120/80 mmhg
SYSTEMIC EXAMINATION:
ULCER ON INSPECTION-
A Solitary oval ulcer which was 10cm * 6 cm present over the dorsum of left foot.
Serous discharge is seen
ON EXAMINATION OF THE RIGHT FOOT:
Ulcer of size 2*2cm present on the sole of right foot
CVS: S1 and S2 heard. No murmurs heard.
CNS: consious and coherent , normal sensory and motor responses
PER ABDOMEN: Soft and tender. No organomegaly.
RESPIRATORY SYSTEM: Normal vesicular breath sounds
INVESTIGATIONS:
On 9/01/2021
8 Am 172 mg/dl
10 Am 136 mg/dl
2 Pm 143 mg/dl
7 pm 167 mg/dl
On 10/01/2021
8 Am 155mg/dl
Post lunch blood sugar
Haemogram
DATE-7/1/2022
ULTRASOUND REPORT-5/1/2022
ULTRASOUND REPORT-6/1/2022
Urine protein /creatinine ratio
Glycated haemoglobin
PROVISIONAL DIAGNOSIS:
Diabetic ulcer on the left foot
TREATEMT:
Debridement and disarticulation of the 5th toe.
Inj.MONOCEF-1gm - I.V BD
Inj.CLINDAMYCIN 600mg- I.V BD
Inj.NPH INSULIN s.c. BD
Inj. HUMAN ACTRAPID INSULIN 100 mg s.c TID
Tab.PAN 40mg -OD
Tab.CHYMEROL-FORTE -TID
Tab.LIMCEE OD
Tab.DOLO 650mg -TID
Lower limb elevation
Regular dressing of the left foot
Monitor blood glucose level before and after every meal and fasting.
No comments:
Post a Comment