54 yr old male DIABETIC FOOT

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan

29 NOVEMBER 2023

A 54 yr old male Patient came to causality with complaints of

Fever since 5 days

SOB since 5 days

Vomiting for 3 days

History of present Illness::- The patient was apparently asymptomatic 5 days back then he developed fever, which is of high grade associated with chills and rigors.not relieved on taking medication .

He complaints of Shortness of breath since 5 days, which is grade lll 

No orthopnea and paroxysmal nocturnal dyysuria.

Also presents with vomitings since 3 days,2-3 episodes of per day which is non bilious, non blood stained , watery, episodes.

There was an ulcer over left foot since 4 month which is associated with edema foot.

He developed blebs over plantar aspect of the  left leg which made him difficulty in walking.

Past History::-

N/K/C/O DM II since 14 years, on Metformin 500 mg and Glimiperide 1 mg BD

K/C/O Hypertension since 20 yeats , on Amlodipine 5 mg.

Personal History::-

Patient is a vegetarian since childhood

Decreased -appetite

Regular- Bowel and bladder

Adequate -sleep 

Family History::-

Both of the parents mother and father had diabetes.

Father was on medication.

General Examination::-

No Pallor, icterus, cyanosis, clubbing, lymphadenopathy.

KomolEdema of  left foot upto ankle

VITALS::-

BP - 80/60 mm Hg

PR- 104 bpm

RR- 18 cpm

Afebrile

Systemic Examination::-

CVS- S1 S2 + heard,no murmurs

RS- BAE+ ,Normal vesicular breath sounds present

CNS- No focal neurological deficit 

P/A - Soft, Non tender 

Investigation::-

26/11/23 

Rbs- 311 mg/dl 



PROVISIONAL DIAGNOSIS 

    TYPE 2 Diabetes mellitus 

    Left diabetic foot and HYPERTENSION 

   TREATMENT 

  1) IV fluids NS 100ml/hr 

   2) INJ H. ACTRAPID Sc / TID ( acc to GRBS info ) 

   3) GRBS monitoring 

   4 ) BP monitoring hourly 

   28/11/2023 

O/E 

    PR 92bpm

    BP  140/90

     RR 26cpm 

    GRBS  157mg/dl 

    CVS - s1s2 heard no murmurs 

    PA - soft non tender 

   RR - nvbs 

  CNS - no focal neurological deficit 

  FBS 

  PLBS - 178 mg/dl 

  Rx : 

   1) iv fluids 75ml / hr 

    2) inj AUGUMENTIN 1.2g IV/BD ( 9am ; 8 pm ) 

   3 ) inj PIPTAZ 4.5g TID (8am , 1pm ,8pm ) 

   4 )T linezolid 600mg BD 

   5) inj H ACTRAPID SC TID ( 6u;6u;6u ) 

   6 ) inj NPh sc bd ( 4u ;4u ) 

  7) T LASIX 40 mg bd 

   8) T ecospirin 75 mg OD 

   9) GRBs 

   10 ) temp monitoring 4 hrly 

  11) T AMLODIPINE 5mg OD 

  12 ) T CHYMORAL FORTE bd 

  13) T CILASTOL 100 mg BD 

  14) T ATORVASTATIN 40 mg OD