A CASE OF DIABETIC ULCER
MEDICINE CASE DISCUSSION
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.
PAVITRA BALDAWA
ROLL NUMBER -104
9 TH 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:
Ulcer on the left foot since 1 week
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 1 week 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 give some tablets and ointment but the ulcer dint not reduce.
No history of fever,nausea, vomiting,
No history of swelling of the leg
History of serious discharge present which was foul smelling and not blood stained ,reduced on medication.
No history of loss of sensation present in the lower limbs
No history of burning sensation of bilateral lower limbs
No history of weakness of bilateral lower limbs,confusion,altered sensorium
No history of intermittent claudication,rest pain
PAST HISTORY:
He was diagnosed with diabetes 17 years ago since then he is on regular medication-inj MIXTARD.
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- occasionally drinks alcohol
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
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:
Post lunch blood sugar
- 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.
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