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
Ten days PTA

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

11. Physical Examination On Admission (11/9/09) 12/11/09
Conscious, coherent, wheelchair-borne, not in cardiorespiratory distress
Conscious, coherent, not in cardio respiratory distress, afebrile, wheelchair- borne
BP: 100/70mmHg
PR: 80bpm, regular
RR: 20 breaths/min, regular
T: 36.5° C
BP: 120/90mmHg
RR: 18 breaths/min, regular
T: 37.5° C
Ht: 165cm
Wt: 71kg
BMI: kg/m2, normal weight
Wt: 71 kg

12. Physical Examination On admission (11/9/09) 12/11/09 Skin
Warm, moist skin, no active dermatoses
no discoloration nor hyperpigmentation, no aloepecia, warm
HEENT
Pink palpebral conjunctivae, anicteric sclera, pupils 2-3 mm ERTL
No nasoaural discharge, nonhyperemic
PPW, tonsils not enlarged
Supple neck, thyroid not enlarged, no palpable cervical lymph nodes, no masses
Red font should be the first part of the CV PE? There were no red fonts po.

13. Physical Examination On Admission (11/9/09) 12/11/09 Respiratory
Symmetrical chest expansion, no retractions, clear breath sounds
Cardiovascular
Adynamic precordium, AB 5th LICS MCL, normal S1, S2
(-) murmurs
Pulses
No cyanosis, pulses full and equal

14. Physical Examination On Admission (11/9/09) 12/11/09 Gastrointestinal
Flat soft abdomen, normoactive bowel sounds, no masses
Musculoskeletal
(+) 3X3cm tender ulceration at medial calcaneal area of left foot with erythema, edema and yellowish discharge
Left and right with crepitations on pe. But more pronounced on the left knee

15. Physical Examination Neurologic Exam On Admission (11/9/09) 12/11/09
GCS
15(E4,V5,M6)
Motor
Normal muscle bulk and tone; no atrophy of thenar and hypothenar eminences, MMTs 5/5 on both UE and LE
Sensory
(-) sensory deficits, (-) Babinski,
Reflexes
DTRs ++ on all extremities
Coordination
Unable to walk due to swelling and pain, limited movements

16. Physical Examination Cranial Nerves On Admission (11/9/09) 12/11/09
(-) anosmia; (+) ROR, clear disc margins; pupils 2-3 mm ERTL,
EOMs full and equal; V1V2V3
intact; raises eyebrows equally, clenches jaw, smiles and puffs cheeks; (-) facial asymmetry, (+) corneal reflex; (+) bilateral gag
reflex, uvula midline on
phonation; shrugs shoulders
equally against resistance; tongue midline on protrusion