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Approach to a P atient with Diabetic Foot

Approach to a P atient with Diabetic Foot . Fajardo , Revie – Garcia, Louise B3-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 foot

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Approach to a P atient with Diabetic Foot

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  1. Approach to a Patient with Diabetic Foot Fajardo, Revie – Garcia, Louise B3-B Dra. Ong-Mateo

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

  3. Chief Complaint Swelling of the left foot Current Working Diagnosis: Diabetic Foot, Left Foot; DM Type 2 poorly controlled

  4. History of Present Illness

  5. 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

  6. 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

  7. Family History • (+)DM: sister- deceased due to ‘heart attack’ (52 years old) • Father deceased- sudden death • (+)cataract: mother • (-) asthma, HPN, CA

  8. Review of System GENERAL 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

  9. Review of System 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

  10. Review of System NEUROLOGIC: ( - ) numbness ( - ) tingling ( - ) burning ( - ) sharpness ( - ) motor weakness ENDOCRINE: ( + ) polydipsia ( + ) polyphagia ( - ) heat/cold intolerance HEMATOPOIETIC: ( - ) bleeding tendency ( - ) bruisability

  11. Physical Examination

  12. Physical Examination

  13. Physical Examination

  14. Physical Examination

  15. Physical Examination

  16. Physical Examination

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