70M Rt.DIABETIC FOOT ; K/C/O HTN & DM2 SINCE 2 YEARS
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Wound on the Right Foot Since 2 Years
Difficulty in Passing Urine Since 1 Year
Tingling & Numbness in Both UL & LL Since 6 Months
Fever Since 1 Day
History of Present Illness:
2021 :
Usually Weekly Once He goes to bring firewood by Cutting Trees at near by place for Cooking. Similarly he went to get firewood and Sustained a Thorn Prick to Rt.Foot & Had Pain but managed to Walk with that pain & He also walked in Rain mud.After that he developed Ulcer which was not healing for Which he went Nalgonda District Hospital Where he admitted for around 20 days & Was Diagnosed With Diabetes & HTN and was discharged with Medication ( Tab.METFORMIN & Tab.AMLODIPINE ) after removing a part of dead tissue around the Wound
2022 :
Patient Developed Difficulty in Passing Urine & Was having Urgency , Hesitancy & Feeling of Incomplete Voiding of urine for which he went to Hospital in Nakrekal & Was prescribed some medication ; Dressing was Done for the wound after which the symptoms are Improved.After that he was having Similar Complaints Occasionally & Gets Relieved by Medication. Later his Rt. 3rd toe was becoming thin ; For which he went to Nalgonda district hospital & Where they checked & was informed no Toe was left & Was amputated.
Pyscho Social History :
3 years Back ( 2020 ) :
He was daily Wage Labourer in a Rice Mill in Nakrekal by Occupation & Used to earn ( Rs: 100/day ) ; Used to go on every alternate day but Stopped working 3 years back after the death of his Wife due to both knee joint pains & not able to cope up that Work of lifting Rice Bags
Financial Burden : After Stopping the work he has no Source of Income & Manages to Live by Pension Money ( Rs:2000/Month )
His Wife died 3 years ago ; children have left the house ,settled in other parts of the city and they do not maintain contact with their father, he lives all alone in his rural house ( 1 Small Room ), no care taker
Alcohol Habbit : He used to Drink Sara Packets ( Rs 1 / Packet ) when he was working in Ricemill ; He Used to drink daily 2-3 Packets after Work. After Stopping work also he drank for about 1 year ( Toddy ).But stopped after He developed wound on the Foot.
Diet Habbits : Before diagnosing diabetes he used to eat Rice 3 times a day & After he started eating jonna Gatka 3 times a day
Daily Routine :
His day begins early in the morning when he needs to wake up even when he does not feel like, because he knows that he has to get going ,to fill vessels of water for the day, for drinking and household chores ,and after a certain time , the source water stops, hence that is the way the day begins ,
Even though the foot is painful, and he is weak with the burden of age and life events ,he has no other option but to pull himself up and head towards making some food for himself , he has somehow managed to buy a small cooking gas cylinder in which he cooks his 2 square meals of the day, which mostly comprises of Jonna Gatka.He wouldn't mind to eat a better variety and maybe a more healthier plate but his resources and energy to make the meals by himself is too constrained to even think of those options.
After his meal preparation, he eats his food , takes some rest , and then again gets started in washing the used utensils , and once in couple of days cleaning the room.
Through the day, In between the works he tries to rest at times , In the late afternoons , some days he goes out to buy small necessary things ,going and coming back,takes a lot of time,since he walks slowly with the assistance of a stick.Later at night he finishes his dinner & goes to bed.
General Physical Examination:
Patient is conscious, coherent and cooperative He is Moderately built and moderately nourished
No signs of Pallor, Icterus, Cyanosis, Clubbing, Lymphadenopathy, Edema
Vitals at Presentation :
Patient is conscious,coherent, cooperative & well oriented to time place person
BP-140/80 mm of Hg
PR - 88bpm
RR - 16cpm
Temp-100F
Spo2 - 98% on Room Air
Systemic examination:
PER ABDOMEN
Inspection:
No Abdominal distension
No scars, sinuses, mass visible
Palpation:
Inspectory findings are confirmed
No local rise of temperature
No Tenderness present
Auscultation:
Normal bowel sounds heard
RESPIRATORY SYSTEM EXAMINATION
Inspection:
Bilaterally Symmetrical chest movements present
No scars and sinuses
Trachea central
Palpation:
Inspectory findings are confirmed
Percussion:
Resonant note present in all lung areas
Auscultation:
Normal vesicular breath sounds heard.
CARDIOVASCULAR SYSTEM EXAMINATION
Inspection :
Bilaterally symmetrical chest present
No scars, sinuses
Palpation:
Inspectory findings are confirmed
Apex beat is in left 5th ICS half inch Medial to Midclavicular Line
On Auscultation :
S1 S2 heard, no murmurs or additional heart sounds
