35 yr old male with foot ulcer and uncontrolled sugars.

This is an 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 patient's 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 the comment box.


Case

A 35 year old male who is a Biochemistry teacher by occupation, resident of nalgonda came with chief complaints of
- pain in the lower chest region on left side, since 5 days 
- vomitings since 3 days

History of presenting illness :

 √ Patient was apparently asymptomatic 8 years ago. He then had a fall (giddiness) and was taken to hospital and was diagnosed with diabetes. 
 √ 4 years back, he noticed a corn on his left toe. He treated it on his own by cutting the superficial layer and dressing with spirit and iodine. It later developed into an ulcer. The ulcer was debrided 2 years back and 6 months. 
 √ 3 years ago, he quit his job. And became chronic alcoholic, consuming about 370 ml of alcohol per day along with smoking (5-6). He developed pain in abdomen and vomitings. He was diagnosed with acute pancreatitis on consultation and got treated. 
 √ 2 years ago, he attempted suicide by consuming OP poison and was admitted and treated for it. 
 √ 2 weeks ago, he met with an accident. After 3 days he developed left lower chest pain. He also has complaints of vomittings since 3 days which were non projectile, non bilious and had food particles as content. He had only one episode of blood in vomitus 3 days back. 
He reports intolerance on drinking water and feels nauseous as soon as he consumes water. 
 √  He was on zofer and after 2 days his vomitings subsided. He was also on insulin due to increased blood sugar levels. He had an allergic reaction to insulin so he was then put on oral medications. 





Past history

▪ Known case of diabetes since 8 years 

▪ No history of hypertension, asthma, epilepsy, CAD. 

Family history
 Not significant

Personal history 
* Diet- mixed
* Appetite- normal ( does not take food when he consumes alcohol )
* Sleep- inadequate( when he does not take alcohol)
* Bowel and bladder movements- regular
* Habits- consumes alcohol from 2009 occasionally but from 2019 consumed daily , smokes while drinking about 5 to 6 each time. 


General examination

 Patient was conscious , coherent, cooperative well oriented to time , place person 

Pallor- mild
icterus- absent
cyanosis- absent
clubbing- absent
Lymphadenopathy - absent
Edema- absent


VITALS-

Temp: 98°F
PR: 78bpm
RR: 18 cpm
BP: 120/80 mm hg
SpO2: 98% on RA



Systemic examination

CARDIOVASCULAR SYSTEM- 

Inspection- 
The chest wall is bilaterally symmetrical.
No dilated veins, scars or sinuses are seen
Apical impulse or pulsations can be appreciated in sixth intercostal space 2cms lateral to mid clavicular line

Palpation-
Apical impulse is felt in the sixth intercostal space, 2 cm away from the midclavicular line
No parasternal heave or thrills are felt 

Percussion- 
Right and left borders of the heart are percussed 

Auscultation-
S1 and S2 heard, no added thrills and murmurs are heard

 RESPIRATORY SYSTEM-  
Inspection-
Chest is bilaterally symmetrical
The trachea is positioned centrally
Apical impulse is not appreciated 
Chest moves normally with respiration
No dilated veins, scars or sinuses are seen

Palpation- 
Trachea is felt in the midline 
Chest moves equally on both sides 
Apical impulse is felt in the sixth intercostal space 
Tactile vocal fremitus- appreciated 

Percussion-
The areas percussed include the supraclavicular, infraclavicular, mammary, axillary, infraaxillary, suprascapular, infrascapular areas.
They are all resonant.

Auscultation-
Normal vesicular breath sounds are heard

 • Abdomen- no tenderness seen, no palpable mass seen, not distended


CNS-
Patient is conscious
Speech -normal
No meningeal signs.

SENSORY EXAMINATION,- touch, pain , vibration present
No muscle wasting seen
Tone of muscles is normal

▪REFLEXS:-
 • Deep tendon reflexes

                              Right.                      Left

  Knee jerk.             +2                          +2
  Ankle reflex.         +2                          +2    
  Biceps.                  +2.                         +2      
  Triceps.                  +2.                        +2
  Supinator.             +2.                         +2    
  
•Power
                             Right                      Left 
Biceps.                  5/5.                       5/5
Triceps.                 5/5.                       5/5
Extensors of knee
                               5/5.                         5/5      Flexors of knee
                                5/5                       5/5
Exetnsors of hip
                                 5/5.                     5/5
Flexors of hip
                                5/5                       5/5

•Gait -normal
▪Coordination
- Finger nose test-able to perform
- knee heel test- able to operform
- Romberg sign- negative

Investigation
 



 ▪ 15/3/2022

 S. Lipase:  48 IU/L (0-160)
S. Amylase: 74 IU/L (40-140)

Urine for ketone bodies: negative 

•LFT: 
TB: 1.08 (0-0.8)
DB: 0.24(<0.3)
AST: 18(10-34)
ALT: 10(10-130)
Alk P: 242(24-147)
TP: 7.3(5.2-8.2)
Alb: 4(2.4-4)
A/G: 1.23

•ABG:


USG ABDOMEN


 
• Chest x ray AP view

 

• ECG


Serum creatinine: 1.0
Serum urea: 15

•Hemogram: 
Hb: 10.5
TLC: 5,400
N:65
L: 28
PLT: 2.30

 •Electrolytes
Na: 138
K: 4.1
Cl: 99

▪ 17/03/2022

Hba1c- 8.1

 Provisional diagnosis

 •Uncontrolled sugars with diabetic left foot(great toe) ulcer.
•RTA with left 7th rib fracture, alcohol dependency

Treatment
  
Tab - Glimeperide 4mg morning, night 3 mg. 
Tab - Metformin 500mg bd
Tab - Pantoprazole 40 mg
Tab - Dolo 650 mg
Tab-Ultracet 1/2 tab QID


Acknowledgement:
https://aitharaveena.blogspot.com/2022/03/35-year-old-male-with-pain-in-loqer.html

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