GM CASE 1

February 21st ,2023

GM CASE 1 

Case scenario....
Hi, this is G sai kaushik yadav ,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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