diabetic foot ulcer with CKD
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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.
D. Shreeya , 8th sem ,roll no 39
A 49yr old male contracter by occupation r/o nalgonda came to OPD with chief complaint of swelling in the right leg since 20days and fever since 1 week.
History of presenting illness
Patient was apparently asymptomatic 20days back then he developed pain in the right lower limb and for which he went to Near by hospital and treated with antibiotics and then he developed swelling in the lower limb which is insidious in onset ,gradually progressive ,pitting type initially at ankle ,extended till knee then he developed a bubble like thing in the dorsum of the right foot which bursted and developed into an ulcer
H/o fever since 1week which is intermittent associated with chills and rigors.
No h/o burning micturition ,and decreased urine output
Patient developed shortness of breath 2yrs back and came to our hospital and diagnosed with heart disease (CAD)and renal disease and he was referred to Hyderabad kims and was treated and symptoms subsided
Daily routine
He wakes up in the morning 5'o clock goes to narketpalli and come back by 7am and have lunch and then go back to nky for site visit and come back by 5pm then at night he will have the dinner and go to sleep by 11pm
Past History
Diabetes since 12 yrs and using glimepiride
Hypertenstion since 12yrs for which he is using nifidipine
No History of asthma, Epilepsy, Tuberculosis
Had a History of dialysis
1st on 22/7/22
2nd on 24/7/22
3rd time on 21/7/22
4th time on on 29/7/22
Personal History
Diet-mixed
Appatite-normal
Sleep-adequate
Decreased urine output(3 to 4 times a day)
Normal Bowel movements
No addictions
No allergies
Family History
No significant
Treatment history
He is using ecosprin,furasamide,folic acid,bisprostol since 2 yrs
And glicazide since 12yrs for diabetes daily morning
General examination
The patient was consious, coherrent, cooperative Well oriented with time, place and person .well built and nourished
No pallor
No icterus
No cyanosis
Pedal edema
Edema of left hand
Vitals
temp-afebrile(98.6)
Bp-120/90mm of Hg
PR-88bpm
RR-18cpm
Spo2-97%
GRBS-107mg/dl
Systamic examination
Clinical pictures
Investigations
HIV-non reactive
Serum iron-87ug/dl
Anti HCVantibodies -NON REACTIVE
RBS-80mg/dl
Blood group-o(-ve)
HBsAg-negative
CBP
RFT
LFT
USG
ECG
chest x ray
PND-ulcer with CKD
TREATMENT:
Fluid and salt restriction
Tab.NICARDIA XL 30 mg /od
Tab.Bisoprolol 5mg /od
Tab.ecospirn 75/20mg
Tab.lasix 40mg
Tab.Nodosis 500mg/BD
Tab. Orofer xt /po/OD
T.BACT Ointment
Regular dressing compressive crepe bandage.
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