Approach to a Patient 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 Current Working Diagnosis: Diabetic Foot, Left Foot; DM Type 2 poorly controlled

History of Present Illness Ten days PTA

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

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

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

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

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

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

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: 26.08 kg/m2, normal weight Wt: 71 kg

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.

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

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

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

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