Gm case 8

Case scenario....

Hi, this is P.Minnu ,3rd Bds.This is an online eblog book discuss our patient health data after taking his consent.this also reflects my patient centered online learning portfolio.

CASESHEET :    62 year old patient with                            severe diabetic foot infection 

CHEIFCOMPLAINTS  :   left foot infection with draining fluids since 1 month 3days


HISTORY OF PRESENT ILLNESS: patient was having  type 2 diabetes since 11years.
He had fever for a 1week   2months back since then he saw symptoms of swelling of the left leg ankle slowly he developed a small  puncture over that swelling and fluid discharge started slowly since then with this compliant he came to hospital .

ASSOCIATED DISEASES :
Type ll diabetes mellitus
Hypertention 

PERSONAL HISTORY: 
Appetite : Normal 
Diet: Mixed 
Bowel and bladder movements: Regular 
Addictions : Nil
Micturition: normal
Known Allergies : nil

FAMILY HISTORY: 
Patient father is affected 

GENERAL EXAMINATION:
Pallor : no
Icterus :no
Cyanosis : no
Clubbing : no
Lymphadenopathy : no
Edema : no

VITALS:
Temperature: 98.6°c/f
Pulse: 69beats per minute
Respiratory rate: 16cycles per minute
Blood pressure: 130/90 mm of Hg
SPO2: 98%

SYSTEMIC EXAMINATION:

Upper respiratory tract examination:
Left sided deviated nasal septum 
Oral cavity- normal oral hygiene 
Lower respiratory tract :
Inspection :
- shape of chest is symmetrical,elliptical 
- Chest expansion equal on both sides 

Palpation :

All inspectory findings are confirmed with palpation.
 Trachea central in position.
 No local rise in temperature
 No tenderness 
 Chest movements: Equal on both side.

  Cardiovascular Examination:
Thrills: no
Cardiac sounds: S1, S2 heard
Cardiac murmurs: No

PROVISIONAL DIAGNOSIS:
Diabetic foot 

Questions from patient :
1. How long does take to cure?
2. can we diagnose it at early stage ?
3. Any alternative treatment other than surgical removal ?




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