A 60 year old male with High blood sugar levels

 December 16, 2022

This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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.

CASE PRESENTATION 

 

A 60 year old male resident of venugonda came to the general surgery OPD with chief complaint of >swelling and blackish discoluration of left foot to the 2nd toe since 20 days, And he was referred to general medicine for "HIGH BLOOD SUGAR LEVELS".

 

HISTORY OF PRESENTING ILLNESS 

 Patient was apparently asymptomatic 20 days ago and then he noticed swelling over left great and 2nd toe followed by which ulceration occurred which was sudden in onset gradually progressive associated with pain over the ulcer, The pain was on and off dull aching type of pain, which was relieved on medication. 

Blackish discolration of left 2nd toe which was sudden in onset and progressed to involve whole toe.

AND referred to the general medicine department for high blood sugar levels. 

No history of fever, trauma, discharge from wound. 

no history of vomiting, abdominal pain, breathlessness

 

PAST HISTORY 

History of similar complaints in the past over the right foot and dorsum of left foot. 

The patient was a known case of Diabetes mellitus since 3 years {under medication metformin 400 mg}and hypertension since 1 year.[unknown medication]

PERSONAL HISTORY 

Appetite: Normal

Diet: Mixed 

sleep: Adequate 

Bowel and bladder movements: Regular 

Addictions: Alcohol: occasional, no other addictions. 

DAILY ROUTINE 

He wakes up at 6 AM everyday and do his everyday rituals then have breakfast at 8AM. Then he go to his work, and have his lunch at 2 PM and comes to home by 8 PM and have dinner at 9 PM and goes to sleep at 11 PM 

FAMILY HISTORY

There are no complaints in the family 

 

GENERAL EXAMINATION 

Patient is conscious, coherent, cooperative well oriented to time, place and person. He is moderately built and nourished.

No pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema. 

VITALS: 

Temperature: Afebrile 

BP: 140/90 mmhg 

pulse rate: 90bpm 

Respiratory rate: 14 cpm

GENERAL EXAMINATION: 

        CVS: 

INSPECTION: 

Shape of chest: bilaterally symmetrical 

No visible pulsations 

No scars, sinuses, dilated veins

PALPATION: 

No thrills, parasternal heaves 

AUSCULTATION: 

S1, and s2 sounds are heard 

No murmurs 

 

No raised jvp 

RESPIRATORY SYSTEM 

Bilateral air entry present

Normal vesicular breath sounds are heard 

PER ABDOMEN

soft,non tender,no organomegaly

CNS

 No focal neurological deficit