drshivakumar

A 48 YR OLD FEMALE FARMER BY OCCUPATION RESIDENT OF VELLEMLA CAME WITH CHIEF COMPLAINTS:

WOUND OVER THE LEFT FOOT SINCE 4 MONTHS

HISTORY OF PRESENT ILLNESS:

PATIENT WAS APPARENTLY ASYMPTOMATIC 4 MONTHS BACK, AFTER WHICH SHE DEVELOPED BLACKISH DISCOLORATION OF LEFT GREAT TOE WHICH WAS INSIDIOUS IN ONSET GRADUALLY PROGRESSIVE, ASSOCIATED WITH SWELLING OF THE LEFT LIMB TILL MID FOOT FOR WHICH SHE WENT TO A LOCAL PRACTITIONER AND WAS TREATED WITH DRESSING THERE WAS NO IMPROVEMENT, WITH PROGRESSION OF WOUND, ASSOCIATED WITH FOUL SMELLING DISCHARGE FOR WHICH SHE WAS TAKEN TO AN OUTSIDE HOSPITAL WHERE DIS ARTICULATON OF LEFT GREAT TOE WAS DONE ON 13/04/24

CAME ON LAMA TO OUR HOSPITAL FOR FURTHER MANAGEMENT

NO H/O FEVER,COUGH,COLD.

NO H/O CHEST PAIN, PALPITATIONS, BREATHLESSNESS, ORTHOPNEA, PND.

NO H/O ABDOMINAL PAIN, BURNING MICTURITION, NAUSEA, VOMITING.

DALIY ROUTINE :

WAKES UP AT 6 AM IN THE MORNING

DRINKS TEA AND DOES HOUSEHOLD WORK

HAVE BREAKFAST FAST AT 9 AM

GOES TO THE FIELDS

EATS LUNCH AT 2 PM

DOES WORK IN THE FIELDS(PADDY AND COTTON FIELDS)

DRINKS TEA IN THE EVENING AT 5 PM

DOES HOUSEHOLD WORK

EATS DINNER AT 8 PM

SLEEPS AT 10 PM

DECREASED WORKING ACTIVITIES SINCE 6 YEARS WHEN SHE WAS DIAGNOSED WITH DIABETES

HISTORY OF PAST ILLNESS:

K/C/O TYPE 2 DIABETES MELLITUS SINCE 6 YEARS (ON TAB GLIMI M1/OD)

NO H/O HYPERTENSION, ASTHMA, TB, EPILEPSY, CVA,CAD,CKD,CLD.

TREATMENT HISTORY:

ON TAB.GLIMI-M1 PO/OD

PERSONAL HISTORY:

MARRIED

OCCUPATION: FARMER

APPETITE: NORMAL

DIET: MIXED

BOWEL AND BLADDER: REGULAR

KNOWN ALLERGIES: NO

ADDICTIONS: NO

FAMILY HISTORY:

NO SIGNIFICANT HISTORY,

GENERAL EXAMINATION:

PT IS CONCIOUS, COHERENT AND COOPERATIVE, MODERATELY BUILT AND NOURISHED.

PALLOR PRESENT.

NO ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA.

TEMP-97.6 F

PR- 86 BPM

RR -18 CPM

BP - 80/50 MMHG

SPO2-98% AT RA

GRBS-164 MG/DL

SYSTEMIC EXAMINATION:

CVS- S1,S2 HEARD, NO MURMURS

RS-VESICULAR BREATH SOUNDS HEARD, NO WHEEZE AND DYSPNEA.NO CREPTS

P/A-SOFT, NON-TENDER, NO ORGANOMEGALY

CNS

LEVEL OF CONSCIOUSNESS : CONSCIOUS

SPEECH: INCOHERENT

SIGNS OF MENINGEAL IRRITATION: NEGATIVE

CRANIAL NERVES: NAD

MOTOR SYSTEM:

UL LL

TONE - NORMAL NORMAL

NORMAL NORMAL

POWER: 5/5 5/5

GLASGOW SCALE: E4 V5 M6

REFLEXES:

Right Left

BICEPS 2+ 2+

TRICEPS 2+ 2+

SUPINATOR + +

KNEE 2+ 2+

ANKLE NOT ELICITABLE +

PLANTARS - FLEXOR

LOCAL EXAMINATION OF LEFT FOOT :

INSPECTION -

ULCER OF SIZE 5×4 CMS OVER THE DORSUM OF THE LEFT FOOT

SURROUNDING SKIN APPEARS TO BE NORMAL

MARGINS ARE IRREGULAR

EDGES ARE SLOPING

FLOOR IS COVERED BY SLOUGH AND GRANULATION TISSUE

PALPATION -

TENDERNESS +

NO LOCAL RISE OF TEMPERATURE

ALL INSPECTORY FINDINGS ARE CONFIRMED

BASE IS UNDERLYING FASCIA AND BONE

COURSE IN THE HOSPITAL:

48 YEAR OLD FEMALE CAME TO CASUALITY WITH CHIEF COMPLAINTS OF WOUND ON LEFT FOOT SINCE 4 MONTH.

PATIENT WAS APPARENTLY ASYMPTOMATIC 4 MONTHS AGO THEN SHE DEVELOPED BLACKISH DISCOLORATION OF LEFT GREAT TOE SINCE 4 MONTHS, INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE ASSOCIATED WITH SWELLING OF LEFT FOOT

PATIENT INITIALLY WENT TO OUTSIDE HOSPITAL IN HYDERABAD AND GOT DISARTICULATION OF LEFT GREAT TOE ON 13/04/2024 AND WAS ON IONOTROPIC SUPPORT AND WAS MANAGED THERE FOR 4-5 DAYS AND THEY GOT LAMA DISCHARGE FROM HOSPITAL DUE TO PERSONAL REASONS.

AS PATIENT CAME WITH FOLEYS IN SITU, FOLEYS WAS CHANGED ON THE DAY 1 OF ADMISSION AND DE CATHETERISED ON DAY 5 OF ADMISSION.

ON ARRIVAL PATIENT BP-90/50 MMHG WITH NORAD 4 ML/HR

GRBS-165 MG/DL ON INJ. INSULIN HAI SC/TID.

PATIENT WAS ADMITTED IN ICU AND WAS STARTED ON INJ. HAI SC/TID AND INJ. NPH BD ACCORDING TO RBS LEVELS.

IONOTROPES INJ. NORADRENALINE AND INJ. VASOPRESSIN INFUSIONS STARTED AND TITRATED ACCORDINGLY TO MAINTAIN MAP(MEAN ARTERIAL PRESSURE) >65 MMHG.

PATIENT TREATED WITH BROAD SPECTRUM ANTIBIOTICS, NECESSARY INVESTIGATIONS WERE DONE AND BLOOD, URINE CULTURE AND SENSTIVITY SAMPLES SENT AND OTHER NECESSARY INVESTIGATIONS WERE DONE PATIENT WAS STARTED ON DUAL IONOTROPES AND RIGHT IJV TRIPLE LUMEN CATHETERISATION WAS DONE 21/04/24 UNDER ASEPTIC CONDITIONS AND THE PROCEDURE WAS UNEVENTFUL; WOUND DRESSINGS WERE DONE ON REGULAR BASIS AFTER CROSS CONSULTATION WITH GENERAL SURGERY.

GENERAL SURGERY ON 19/04/24 I/V/O DIABETIC ULCER OVER LEFT FOOT:

1. HIGH PROTEIN DIET. (DIABETIC PROTEIN POWDER 2 TBSP IN GLASS OF MILK PO/BD)

2. T.CHYMEROL FORTE PO/TID.

3. BOTH LOWER LIMB ELEVATION.

4. REGULAR ASD(MGSO4 DRESSING FOR LEFT LOWER LIMB).

IONOTROPIC SUPPORT WAS STOPPED ON 23/4/2024 AND PATIENT IS HEMODYNAMICALLY STABLE

BLOOD TRANSFUSION (1 UNIT PRBC) DONE ON 25/04/2024 I/V/O HEMOGLOBIN-7.6G/DL POST TRANSFUSION Hb 10.2 G/DL,

GENERAL SURGERY REFERRAL WAS DONE ON 24/04/24 I/V/O DIABETIC ULCER OVER LEFT FOOT DEBRIDEMENT OF ULCER AND PAPAYA DRESSING DONE.

DURING THE STAY IN THE HOSPITAL, PATIENT WAS ACTIVELY AMBULATED, FROM DAY 4 OF ADMISSION HEALTHY GRANULATION TISSUE WAS FORMED IN THE WOUND PATIENT IS BEING DISCHARGED AS SHE SHOWED SIGNS OF PROGRESSIVE HEALING AND IS HEMODYNAMICALLY STABLE, WITH GLYCEMIC CONTROL.