Approach to a Patient with Diabetic Foot

Fajardo, Revie – Garcia, LouiseB3-B

Dra. Ong-Mateo

General Data

• A.B• 49/M• Filipino• Roman Catholic• Paranaque City• Married• Fruit Vendor• Date of Admission: Nov 9, 2009

Chief Complaint

Swelling of the left footCurrent Working Diagnosis: Diabetic Foot, Left

Foot; DM Type 2 poorly controlled

History of Present Illness

Ten days PTA

Past Medical History

• Immunizations: unrecalled; BCG• Hospitalizations: non-healing wound (lateral aspect of

left leg): treated w/ unrecalled antibiotics (1997)• hemoptysis: treated w/ quadruple anti-TB

therapy(HRZE) Myrin Forte 6 months (approx. 5 yrs ago)

• Diabetes Mellitus type2 (1997)• Maintenance medications: Glibenclamide 500mg od• No surgery• No allergies

Personal and Social History

• 16 pack year smoking 17 y.o.- 25 yo—2packs/day

• Alcohol drinker almost every night 2 bottles of beer

• Mixed diet composed of meat, fish, vegetables and fruits cautious with sweets

• Exercise is with his sidecar (padyak) used in selling fruits

• Sleeps for 4-6 hours a day

Family History

• (+)DM: sister- deceased due to ‘heart attack’ (52 years old)

• Father deceased- sudden death• (+)cataract: mother• (-) asthma, HPN, CA

Review of SystemGENERAL SURVEY:( - ) fever( - ) weight loss( - ) weakness( - ) fatigability( - ) malaise

SKIN:( +) 4 inch-scar on the lateral

aspect of the left leg ( - ) itchiness( - ) color change( - ) rash

HEENT:( - ) icterus( - ) ear pain/ discharge( - ) nasal discharge( - ) deafness( - ) lymphadenopathy

PULMONARY:( - ) dyspnea( - ) shortness of breath( - ) cough( - ) sputum production( - ) hemoptysis( - ) wheezing

CARDIAC:( - ) chest pain( - ) easy fatigability( - ) paroxysmal dyspnea( - ) orthopnea( - ) palpitations( - ) syncope( - ) edema( - ) hypertension

GI:( - ) nausea( - ) vomiting( - ) retching( - ) hematemesis( - ) melena( - ) hematochezia( - ) belching( - ) distention( - ) diarrhea( - ) constipation

GU:( + ) polyuria( + ) incontinence( + ) erectile dysfunction ( - ) anuria( - ) dysuria( - ) hesitancy

MUSCULOSKELETAL:( - ) rigidity( - ) flaccidity( - ) weakness

Review of System

ENDOCRINE:( + ) polydipsia( + ) polyphagia ( - ) heat/cold intolerance

HEMATOPOIETIC:( - ) bleeding tendency( - ) bruisability

NEUROLOGIC:( - ) numbness( - ) tingling( - ) burning( - ) sharpness( - ) motor weakness

Review of System

Physical Examination

On Admission (11/9/09) 12/11/09

Conscious, coherent, wheelchair-borne, not in cardiorespiratory distress

Conscious, coherent, not in cardio respiratory distress, afebrile, wheelchair- borne

BP: 100/70mmHg PR: 80bpm, regular RR: 20 breaths/min, regular T: 36.5° C

BP: 120/90mmHg PR: 80bpm, regular RR: 18 breaths/min, regular T: 37.5° C

Ht: 165cm Wt: 71kgBMI: 26.08 kg/m2, normal weight

Ht: 165cm Wt: 71 kgBMI: 26.08 kg/m2, normal weight

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Physical ExaminationOn admission (11/9/09) 12/11/09

Skin Warm, moist skin, no active dermatoses no discoloration nor hyperpigmentation, no aloepecia, warm

HEENT Pink palpebral conjunctivae, anicteric sclera, pupils 2-3 mm ERTL

No nasoaural discharge, nonhyperemic

PPW, tonsils not enlarged

Supple neck, thyroid not enlarged, no palpable cervical lymph nodes, no masses

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Physical ExaminationOn Admission (11/9/09) 12/11/09

Respiratory Symmetrical chest expansion, no retractions, clear breath sounds

Cardiovascular Adynamic precordium, AB 5th LICS MCL, normal S1, S2

(-) murmurs

Pulses No cyanosis, pulses full and equal

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Physical ExaminationOn Admission (11/9/09) 12/11/09

Gastrointestinal Flat soft abdomen, normoactive bowel sounds, no masses

Musculoskeletal (+) 3X3cm tender ulceration at medial calcaneal area of left foot with erythema, edema and yellowish discharge

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Neurologic Exam

On Admission (11/9/09) 12/11/09

GCS 15(E4,V5,M6)

Motor Normal muscle bulk and tone; no atrophy of thenar and hypothenar eminences, MMTs 5/5 on both UE and LE

Sensory (-) sensory deficits, (-) Babinski,

Reflexes DTRs ++ on all extremities

Coordination Unable to walk due to swelling and pain, limited movements

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Physical Examination

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On Admission (11/9/09) 12/11/09

Cranial Nerves (-) anosmia; (+) ROR, clear disc margins; pupils 2-3 mm ERTL, EOMs full and equal; V1V2V3 intact; raises eyebrows equally, clenches jaw, smiles and puffs cheeks; (-) facial asymmetry, (+) corneal reflex; (+) bilateral gag reflex, uvula midline on phonation; shrugs shoulders equally against resistance; tongue midline on protrusion

Physical Examination