40 Y F with wound over the right heal since 3 months

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I’ve been assigned this case as an intern in an attempt to understand the topic of ‘patient clinical data analysis’ to improve my competency in reading and comprehending the clinical data including history, clinical findings, investigations and come up with a diagnosis and the treatment plan.

CONSENT AND DE-IDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.

Presenting complaints:

40 year female came to GM OPD with chief complaints of wound over the right heal and left 1st and #nd toe since 3 months.

Swelling over the left gluteal region since 3days

Fever since 3 months

Itching over the bilateral thigh since 3 months.

Discharge from left eye since 3 months

Pain over left side of face with tingling sensation.

HOPI:

Patient was apparently asymptomatic 3 months back then she noticed whitish blood stained discharge from the wound over the right heal then she noticed painless sensation over the wound.

Patient went to the consultant and underwent debridement of wound over right heal and advised for follow up.

Wound is associated with swelling of both lower limbs pitting type not associated with pain or local signs of inflammation.

Fever since 3 months with evening rise in temperature intermittent and relieved by taking medication.

Squeezing type of chest pain 

No cough,cold, palpitations, abdominal pain, vomitings 

H/O rat bite 5 days ago to left 1st toe ,2nd toe

Past history:

K/C/o diabetes mellitus type 2 since 10 years

K/C/o hypertension since 3 months used medication for 1 month.

H/o wound over the right heal 5years ago.

Personal history:

Appetite normal

Sleep adequate

Bowels regular

Micturition normal

Consumes alcohol occasionally

General physical examination:

Patient is conscious coherent and cooperative

Pallor present 

 - no icterus 

 - no cyanosis

 - no clubbing of fingers

 - lymphadenopathy 

 - no pedal edema 

 - no malnutrition 

 - no malnutrition 

 - no signs of dehydration 

VITALS : 

 Temp - afebrile

 Pulse rate - 80 bpm, regular rhythm, normal volume

 Respiratory rate - 18cpm

 BP - 130/ mmhg

 SpO2 - 98% at RA 

GRBs -324 msg/dl

SYSTEMIC EXAMINATION : 

 Cardiovascular System 

 - no thrills

 - cardiac sounds S1 and S2 heard

 - no cardiac murmurs 

 Respiratory System 

 - no dyspnea

 - no wheeze

 - tracheal position is central

 - breath sounds : vesicular 

 - no adventitious sounds heard

 Abdomen 

 - shape : scaphoid

 - no scars, striae or engorged veins 

 - bowel sounds heard

 - no bruits, rubs

 - no shifting dullness

 - no fluid thrill

 - no palpable mass

 - hernia orifices : normal

 - liver: not palpable

 - spleen : not palpable

CNS 

 - conscious

 - normal speech

 - cranial nerves

 -sensory system

Touch sensation over the left 1st toe 2nd toe absent

Pain sensation over the left 1st toe 2nd toe absent

Vibration symmetric on both sides

Treatment

1)inj amikacin 500 msg IV/od

2)inj monocef 1gm IV/BD

3)inj human actrapid insulin SC tid

4)inj nph SC bd

5)fudic cream l/a BD x1week

6)tab teczine 10 mg of X 2 weeks

7) liquid paraffin l/a BD x 2 weeks

8)tab Telma 40 mg po od

9)tab orofer xt po od