A CASE OF DIABETIC ULCER
MEDICINE CASE DISCUSSION
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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.
J . Akash
ROLL NUMBER -43
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 5days
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 5days 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 dint not reduce.
History of serious 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 burning sensation of bilateral lower limbs
No history of weakness of bilateral lower limbs,confusion,altered sensorium.
PAST HISTORY:
He was diagnosed with diabetes 15 years ago since then he is on oral hypoglycemic drugs for 5years& regular medication-inj MIXTARD for last 10years
Similar history of ulcer present on the right foot 3months 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 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. He is well oriented to time ,place and person.
He is sitting comfortably on the bed.
He is moderately build and well nourished
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 added thrills or 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 09/01/2021
8Am 172 mg/dl
10Am 136 mg/dl
2Pm 143 mg/dl
7pm 167 mg/dl
Post lunch blood sugar
Date 7/01/2022
Ultrasound : 05/01/2022
urine protein creatinine ratio
Glycated hemoglobin
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.
10/01/2021
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