A 65 Year old male with diabetes, Hypertension and Right foot injury
I've 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 a diagnosis and treatment plan.
5 YEARS AGO
The patient one day was helping someone who was cutting a tree by holding the branch which was being cut with the help of a rope
He got injured by a stone in the rope to his left palm
This was followed by pain, swelling and blackish discolouration
Then was when he was diagonosed incidentally as diabetic and was kept on medication
He is now on Tab. Metformin 500mg
4 YEARS AGO
He drank and drove following which he had an accident
He drove back home and was taken to hospital from there.There was
1.fracture to his Left ribs (5,6,7) at mid clavicular line
2.Punctured his lung
30 DAYS BACK
While he was going out for work, he stepped over a sharp stone which penetrated through his right little toe
He used medications from the local medical store for about 10 days
He noticed
1. Increase in pain gradual
2. Edema till his knee which was gradual
3. Bleb formation of about 3*3 cm on the dorsum of his foot which he ruptured by piercing a safety pin through it
There was bleeding from the site after piercing and it continued for a few days and formed into an ulcer.
4. Low grade on and off fever
5. There was difficulty in urination
Dysuria
Burning micturition
Hematuria
Reduced urine output
He then went to a government hospital in Nalgonda and was diagnosed to be AKI on CKD and was transferred for private hospital 1 for dialysis
There he developed SOB of grade 2-3, orthopnea and PND
He unwent through Dialysis 1
Due to money restraint the patient was shifted to private hospital-2 9 days back
PRESENTATION
Ulcer of right foot since 20 days
Decreased urine output (dysuria, hematuria, burning micturition ) since 20 days
SOB of grade 2-3, orthopnea, PND since 10 days
Generalised anasarca
DIALYSIS 2
He had itching at his abdomen, back and left and right Axilla
DIALYSIS 3 and 4 done
Patient is feeling better comparatively but still has low urine output and SOB
PAST HISTORY
Alcoholic 90ml everyday since 40 years
Chronic smoker 1 pack since 40 years
Hypertensive since 10 years
Diabetic since 5 years
Not a case of Asthma, tuberculosis, epilepsy
FAMILY HISTORY
The patients mother is diabetic
None of the other family members have similar complaints
DRUG HISTORY
T-Aten-am 50mg
Metformin500mg
No known allergies
PERSONAL HISTORY
Diet- mixed
Appetite- reduced since 3 days
Sleep - inadequate
Bladder - decreased
Bowel- regular
GENERAL EXAMINATION
The patient is coherent conscious cooperative, and well oriented to time place and person
He is moderately built and nourished
Pallor- absent
Icterus- absent
Cyanosis- absent
Clubbing-absent
Edema- present pitting Type
Lymphedenopathy - absent
Vitals:
Temperature- afebrile
Pulse rate- 68 beats per minute
Respiratory rate- 22 breaths per minute
B.P- 160/90 mm hg
SpO2- 99% at room air
SYSTEMIC EXAMINATION
*CVS: S1and S2 are heard
No murmurs are heard
*Respiratory system:
Dyspnoea- present
Breath sounds- decreased breath sounds in right
Vesicular breath sounds are normal
Rt side Fine Crepts present
BAE- positive
*Central nervous system:
Patient was conscious coherent and cooperative.
Speech was normal.
No slurred speech
No meningeal irritation signs
No abnormality detected.
GAIT - Normal
*Abdomen:
Soft and non tender
Investigations:
