Case discussions
Case discussions:
A 55 year old male came to opd who is daily wage worker came with
CHEIF COMPLAINTS:
Swelling over left 2nd toe since 20 days Black discoloration over left 2nd toe since 20days
HISTORY OF PRESENTING ILLNESS:
patient was apparently asymptomatic 20 days back . then he developed swelling over left great and 2 nd toe followed by which ulcreation occurred which was sudden on onset gradually progressive associated with pain over on and off dull aching type . The pain is decreased on medication . also blackish discoloration of left and 2nd toe which was sudden on onset and progressive.
HISTORY OF PAST ILLNESS:
no H/O of fever
no H/O of trauma
no H/O of discharge from wound
H/O of similar complaints in the part over dorsum of left foot
A known case of diabetes since 3 years
A known case of diabetes since 1 year
No history of T.B , epilepsy
No history of blood transfusions.
No history of previous surgeries
PERSONAL HISTORY:
GENERAL EXAMINATION:
Conscious, coherent, co-operative
Moderately built,nourished
PALLOR: present
ICTERUS:ABSENT
CYANOSIS: ABSENT
CLUBBING OF FINGERS/TOES: ABSENT
LYMPHADENOPATHY: ABSENT
PEDAL EDEMA: ABSENT.
VITALS:
TEMPERATURE: 98.4 F
PULSE RATE:90 beats /min
RESPIRATORY RATE:20 Cycles/min
BP:140/90mm of hg
SPO2: 95% at room air
GRBS: high
SYSTEMIC EXAMINATION:
CVS:
S1,S2 Sounds heard,
No audible murmurs,
Thrills:No.
RESPIRATORY SYSTEM:
Dyspnea is absent,
Position of trachea:central,
Normal vesicular breath sounds are heard,
No adventitious sounds
ABDOMEN:
*Abdomen is tense and distended
*Umbilicus is slit shaped
* movement of abdomen moves equally with respiration
* No visible scars.
Palaption:
* No local rise of temperature
* no tenderness present
* No palpable masses found
* Liver and spleen are not palpable
INVESTIGATION:
ECG:
PROVISIONAL DIAGNOSIS:
Dry gangrene of left 2nd toe and Diabetic ulcer over left great and 2nd toe.
TREATMENT :
Inj Agumentin 65 mg iv/ bd
Tab pan 40 mg po/od
Tab solo 659 mg Po/tid
Tab cymeraz forte po/tid
