This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .
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 diagnosis .
COMPLAINTS :
K/C/O Type 2 Diabetes mellitus since 7 years
C/O non healing ulcer of 2nd toe of left foot since 20days
HOPI -
pt was apparently alright 7years ago then he sustained injury to his right leg which didnot heal. Then he consulted the local practitioner and was diagnosed to have diabetes mellitus type 2 and was put on oral hypoglycemic drugs. The wound had become into a non healing ulcer and the right foot was amputated. The blood sugars were not on control with the hypoglycemic drugs and were replaced by insulin .Then 20days back he had trauma to the left foot while riding bike and sustained injury to 2nd toe of the left foot , which was not healing since then.His blood sugars were high and was referred from general surgery OPD.
PAST HISTORY :
K/C/O HTN since 5years on tab. Amlong 5mg po/od
K/C/O type 2 DM since 7years on inj.HAI s/c 15units
Inj. Isophane insulin s/c 15units
N/K/C/O Asthma , TB , epilepsy , CAD , CVA ,Thyroid disorders.
H/O Alcohol intake since 30 years
H/O Cigarette smoking since 30 years
GENERAL EXAMINATION :
Patient is conscious , coherent , cooperative
Moderately built and nourished .
No signs of pallor , icterus , cyanosis , clubbing , lymphadenopathy , edema
Vitals :
Afebrile
PR - 78bpm
BP - 130/70mmHg
RR - 16cpm
GRBS -
CVS - S1S2 heard , no murmurs
CNS - NFND , HMF intact
RS - BAE present , no added sounds
P/A - Soft , non tender , no organomegaly , bowel sounds heard.
GRBS MONITORING :
20/2/23
9 pm - 590mg/dl
11pm - 507mg/dl
21/2/23
1am - 533mg/dl
3am - 546mg/dl
5am - 425mg/dl
8am - 340mg/dl ( 8 units of HUMAN ACTRAPID INSULIN & 4 units of NPH )
10am - 520mg/dl ( 6 units of HUMAN ACTRAPID INSULIN IV given)
1 pm - 289mg/dl ( 14 units of HUMAN ACTRAPID INSULIN )
3pm - 186mg/dl
7pm - 188mg/dl ( 8 units of HUMAN ACTRAPID INSULIN GIVEN )
9pm - 303 mg/dl
2am - 334 mg/dl
22/2/23
8am - 258 mg/dl( 12units of HAI , 8 units of NPH )
10am - 335 mg/dl ( 4units of HAI & Units of NPH)
12pm - 313mg/dl
2pm - 258mg/dl ( 12 units HAI )
8pm - 268mg/dl ( 12 units HAI & 14units NPH )
10pm - 352mg/dl
23/2/23
2am - 229mg/dl
6am - 227mg/dl
8am - 193mg/dl ( 16 units HAI & 16 units NPH )
10am - 240mg/dl
DIAGNOSIS :
UNCONTROLLED DIABETES MELLITUS TYPE 2 WITH NON HEALING ULCER OF 2ND TOE OF LEFT FOOT
INVESTIGATIONS :
TREATMENT :
1.IV fluids at 100ml/hr
2. Inj. Gentamicin 60mg iv/tid
Inj. Metronidazole 500mg iv/tid
2. Inj. Neomol 1gm iv/sos
3. Inj human actrapid insulin s/c acc to sliding scale.( 16 units at 8am , 2pm and 8pm).
4. Inj NPH s/c b/d ( 16units at 8am and 14 units at 8pm)
5. Tab. Pcm 650mg po/tid
6. Tab. Pregaba-m 75mg po/hs
7. Strict diabetic diet.
8. Amputation of the 2nd , 3rd and 4th toe is done under local anaesthesia.( Ankle block ).
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