A 60YR OLD MALE PATIENT WITH DIABETIC FOOT ULCER

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Name : Supriya .K ( Intern ) 

Roll Number : 63 

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. 

 

A 60YRS OLD MALE PATIENT from venugonda came to the general surgery OPD with

 Chief complaints of:   swelling and blackish discoluration of left foot to the 2nd toe since 20 days

(he was referred to general medicine for (HIGH BLOOD SUGAR LEVELS ) - After  RAYS AMPUTATION done 

 

HISTORY OF PRESENTING ILLNESS :

Patient was apparently asymptomatic 20 days ago and then he developed swelling over left 2nd toe followed by which ulceration occurred which was sudden in onset gradually progressive. 

Ulcer is associated with pain ,which is on and off and dull aching type . No aggravating factors but relieved with medication .

He also developed Blackish discolration of left 2nd toe which was sudden in onset and progressive  to involve whole 2nd toe .

(Referred to the general medicine department for high blood sugar levels )

NO H/O fever, trauma, discharge from wound,  vomiting, abdominal pain, breathlessness

 PT UNDERWENT RAYS AMPUTATION: 




PAST HISTORY :

H/O  Similar complaints in the past over the right foot and dorsum of left foot. 

Patient   is  a  K/C/O  Diabetes mellitus since 3 years {under medication metformin 400 mg}.

K/C/O  Hypertension since 1 year.[unknown medication]


PERSONAL HISTORY :

Appetite: Normal

Diet: Mixed 

sleep: Adequate 

Bowel and bladder movements: Regular 

Addictions:  Occasionally alcoholic 

Allergic : No allergies


GENERAL EXAMINATION 

Patient is conscious, coherent, cooperative. Moderately Built , Moderately Nourished .

Pallor - absent 

Icterus - absent 

Clubbing - absent 

Cyanosis - absent 

Lymphadenopathy - absent 

Edema - absent 


VITALS: 

Temperature: Afebrile 

BP: 140/90 mmhg 

pulse rate: 90bpm 

Respiratory rate: 14 cpm

GRBS CHARTING : (17/12/22) :

8AM : 156 mg/dl - 8U HAI ,6U NPH 

10AM : 356 mg /dl 

2PM : 195 mg/dl -8U HAI 

4PM : 252 mg /dl 

8PM : 150 mg/dl - 6U HAI ,6U NPH

10PM : 118 mg/dl 

2AM : 76 mg /dl 

4AM : 169 mg/dl 

8AM : 290 mg/dl - 10U HAI ,8U NPH


17/12/22 (8AM )  TO 18/12/22 (8AM) 

18/12/22 (8AM) to 19/12/22 (8AM) : 

19/12/22 (8AM ) to 20 /12/22 (8AM) : 


SYSTEMIC EXAMINATION : 

CVS : S1 S2 Heard 

RS : BAE + 

CNS :  HMF + 

On Fundoscopy ; No significant changes noted - Diabetic Retinopathy absent ( but advised strict diabetic diet ) 

Motor Examination: 

                     RT                           LT 

Tone :    UL - N                          N

               LL  - N                          N 

Power : UL -4/5                        4/5

               LL- 4/5                        4/5 

Reflexes : biceps: 2+               2+

                  Triceps : 2+            2+

                   Knee: 2+                 2+

                   Ankle : 1+              1+

                  Supinator : 1+          1+

Vibrations : great Toe -  4.22 secs      5.94 secs 

         Medial  malleolus -4.14 secs       4.86secs 

                        Tibia shaft - 5 secs          6secs 

Joint Position :  10%                     10%

P/A : Soft and Non tender 

INVESTIGATIONS: 

USG ABDOMEN: 

Hemangioma in the RT lobe of liver 

Raised echogenesity of bilateral kidneys 

BACTERIAL CULTURE AND SENSITIVITY:

Nature of specimen : Pus Swab

Culture report : Kblesiella Pneumonia species isolated 

SUGAR PROFILE: 

FBS - 440 mg/dl 

PLBS - 386 mg/dl 

HbA1c - 7.8 %













Urine for ketone bodies:  Negative 

2D ECHO : 



Arterial Doppler of B/ L lower limbs : 





Bilateral Arm Muscle Mass and  Visceral Fat :





PROVISIONAL DIAGNOSIS: 

Dry Gangrene of left 2nd toe S/P Rays amputation of 2nd toe 
klebsiella pneumonia detected with in swab c/s resistant to amoxyclav and cotrimoxazole 
AKI on ? CKD 
( k/c/o HTN since 1 year and DM 2 since 3 years ) 

MANAGEMENT: 
Inj Piptaz 2.25gms IV / QID - Day 1
inj HAI s/c according to GRBS 
T. lasix 20mg PO/BD
T. Dolo 650mg Po/Sos 
T. Chymerol forte Po/TID
T. Vit-C PO/OD
GRBS 7 Point profile 
Vitals monitoring 4th hrly 


SOAP NOTES: 

AMC 

Day -4 

Bed -4

unit -3




Stool passed and no fever spikes




Pt is conscious ,coherent , cooperative
Temp: afebrile
BP: 130/80mmHg 
PR : 80bpm 
RR :18 cpm
GRBS :156 mg/dl
CVS : S1 S2 + 
RS : BAE +
CNS :NAD ,HMF+ 
P/A : Soft and nontender 



Dry Gangrene of left 2nd toe S/P Rays amputation of 2nd toe 
Type 2 DM with uncontrolled Sugars 
AKI on ? CKD 
( k/c/o HTN since 1 year and DM 2 since 3 years )




Inj Augmentin 1.2gms IV/BD
Inj HAI s/c according to GRBS
T. Pan 40mg PO/OD                
T. Dolo 650mg Po/SOS.           
T. Chymerol forte Po/TID.     
                T. Vit-C PO/OD                                      
GRBS 7  Point profile 
                      Vitals monitoring 6th hrly.   


AMC 

Day -5

Bed -4

unit -3



Stool passed and no fever spikes



Pt is conscious ,coherent , cooperative
Temp: afebrile
BP: 130/80mmHg 
PR : 84bpm 
RR :18 cpm
GRBS Charting : 
8AM : 156 mg/dl - 8U HAI ,6U NPH 
10AM : 356 mg /dl 
2PM : 195 mg/dl -8U HAI 
4PM : 252 mg /dl 
8PM : 150 mg/dl - 6U HAI ,6U NPH
10PM : 118 mg/dl 
2AM : 76 mg /dl 
4AM : 169 mg/dl 
8AM : 290 mg/dl - 10U HAI ,8U NPH
creatinine clearance : 31ml /min
I/O : 1100/ 800 ml 
CVS : S1 S2 +
  RS : BAE +     
CNS :NAD ,HMF+ 
P/A : Soft and nontender 



Dry Gangrene of left 2nd toe S/P Rays amputation of 2nd toe 
klebsiella pneumonia detected with in swab c/s resistant to amoxyclav and cotrimoxazole 
AKI on ? CKD 
( k/c/o HTN since 1 year and DM 2 since 3 years )




Inj Piptaz 2.25gms IV / QID - Day 1
inj HAI s/c according to GRBS 
T. lasix 20mg PO/BD
T. Dolo 650mg Po/Sos 
T. Chymerol forte Po/TID
T. Vit-C PO/OD
GRBS 7 Point profile 
Vitals monitoring 4th hrly           

AMC 

Day -6 

Bed -4

unit -3



Stool passed and no fever spikes




Pt is conscious ,coherent , cooperative
Temp: afebrile
BP: 100/70 mmHg 
PR : 76bpm 
RR :18 cpm
GRBS Charting : 
8AM : 295mg/dl - 10U HAI ,8U NPH 
10 AM : 290 mg/dl 
2PM : 175 mg/dl - 10U HAI 
4PM : 268 mg /dl 
8PM : 83 mg/dl - 4U HAI ,4U NPH
12AM : 295 mg/dl 
2AM : 311 mg/dl 
8AM : 133 mg/dl - 10U HAI , 6U NPH
creatinine clearance : 32 ml /min
I/O : 900/850 ml 
CVS : S1 S2 + 
RS : BAE +
CNS :NAD ,HMF+ 
P/A : Soft and nontender 





Dry Gangrene of left 2nd toe S/P Rays amputation of 2nd toe 
klebsiella pneumonia detected with in swab c/s resistant to amoxyclav and cotrimoxazole 
AKI on ? CKD 
( k/c/o HTN since 1 year and DM 2 since 3 years )





IV fluids 1. NS @ 50ml /hr 
Inj Piptaz 2.25gms IV / QID - Day 2
inj HAI s/c according to GRBS 
T. lasix 20mg PO/BD
T. Dolo 650mg PO/SOS
T. Chymerol forte PO/TID
T. Vit-C PO/OD
GRBS 7 Point profile 
Vitals monitoring 4th hrly

AMC 

Day -7

Bed -4

unit -3



Stool passed and no fever spikes




Pt is conscious ,coherent , cooperative
Temp: afebrile
BP: 110/70 mmHg 
PR : 76bpm 
RR :18 cpm
Creatinine clearance : 43ml /min 
GRBS Charting : 
8AM : 133mg/dl - 10U HAI , 8U NPH 
10AM : 206 mg/dl 
2PM : 122 mg/dl - 10U HAI 
4PM : 314 mg /dl 
8PM : 135mg/dl 
2AM : 85mg/dl 
8AM : 159 mg/dl - 10U HAI 
CVS : S1 S2 +
RS : BAE +
CNS :NAD ,HMF+ 
P/A : Soft and nontender 


Dry Gangrene of left 2nd toe S/P Rays amputation of 2nd toe 
klebsiella pneumonia isolated in swab c/s resistant to amoxyclav and cotrimoxazole 
AKI on ? CKD 
( k/c/o HTN since 1 year and DM 2 since 3 years )


IV fluids 1. NS @ 50ml /hr 
Inj Piptaz 2.25gms IV / QID - Day 3
Tab.pan 40 mg po/ OD
T. lasix 20mg PO/BD
Tab.Nicardia 10 mg po/BD 
T. Chymerol forte PO/TID
T. Vit-C PO/OD
inj.HAI,NPH s.c/ TID 
(HAI- 10 U 10 u. 8u
  NPH - 6 U. 4u)
GRBS 7 Pint profile 
Vitals monitoring 4th hrly 

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