62yr old male with blackish discoloration of great toe,( post op bradycardia)

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Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.


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NAME: SRI CHANDANA

ROLL. NO: 98

Nov 1, 2023


GENERAL MEDICINE

A 62 yrs old pt came to GS opd with blackish discoloration of left great toe since 15 days.





HOPI

pt was apparently asymptomatic 3 months back and developed a blister on the left great toe and that has ruptured and formed an ulcer which is not healed and that  infection has gradually increased.

15 days back pt came to hospital with blackish discoloration of that great toe. 

No h/o any fever

No h/o itching

No h/o vomitings ( at the time of joining) 


PAST HISTORY:


Patient had similar complaints in the past 1 yr back for the right great toe and got amputated other outside hospital. 

20 yrs back patient suddenly develoed blurring of vision for some time and rushed to a local hospital and found out  that he had diabetes. (Diabetic since 20yrs ) 

Not a k/c/o  HTN, ASTHMA, CVA, TB. 


PERSONAL HISTORY:

Normal appetite

Mixed type of diet and irresistible eating of sweets. 

Regular bowel and bladder movements

There are no allergies for food or any drugs 

Addictions :  patient used to drink and smoke daily in the past  for 40 yrs and stopped10yrs back.


TREATMENT HISTORY:


50yrs back he got amputated his ring finger upto distal Interphalangeal joint because of trauma to that finger. 

Since 20 yrs he is on oral metformin for diabetes. 

2 yrs back he started taking insulin for diabetes. 

1 yr back got amputated his right great toe. 




FAMILY HISTORY: 


His brothers have diabetes


VITALS 

 Temp: 98.7

 Spo 2: 98%

 Bp: 110/60 mm of hg

 RR: 16cycles / min

 Pulse: 66 bpm


GENERAL EXAMINATION:

Pt is well built and malnourished , well cooperative coherent and coordinative. 


pallor : present



Icterus: absent




Cyanosis : absent
Clubbing : absent

Koilonochia : absent

Lymphadenopathy :absent
Pedal edema : mild 



Mid arm circumference 28 cm
Mamc: 23.6 mm
Triceps skinfold thickness:14mm
Abdominal girth: 98cm
Fvf ratio: 98-23.6 =4.15



SYSTEMIC EXAMINATION
Cvs
S1S2 heard 
No murmurs


Respiratory system:
Trachea central
Normal vesicular breath sounds heard


 Cns :
No focal neurological deficits are observed
 

Per abdomen:
Scaphoid abdomen


No tenderness and localised raise of temp. 
No scars and sinuses
No organomegaly
Bowel sounds heard


LOCAL EXAMINATION:

Left leg
After rays amputation

















Healthy granulation tissue is seen 

Margins are regular 

No bleeding 


INVESTIGATIONS:

ECG:

25/10/2023

 



26/10/2023





27/10/2023
30/10/2023



RFT
1) 30/10/2023
2) 25/10/2023
 GLYCATED HAEMOGLOBIN
Blood sugar fasting
28/10/2023


Random Blood sugar

Serological tests


ABG
 LIVER FUNCTION TEST

 APTT
BLEEDING and  CLOTTING TIME

Prothrombin time

Troponin 



Complete urine examination

Liver function test

BLOODGROUPING AND RH TYPING

ULTRASOUND :
25/10/2023




2D ECHO
27/10/2023



TREATMENT
26/10/23
Inj.Meropenem 1gm IV BD
Inj.Metrogyl 500mg IV TID
Inj.Pan 40mg IV OD
Inj tramadol 1 amp in 100 ml
Left lowerlimb elevation
Monitor Temp,PR,BP,SpO2 hourly
GRBS monitoring
liquid diet

27/10/23
Inj.Meropenem 1gm IV BD
Inj.Metrogyl 500mg IV TID
Inj.Pan 40mg PO OD
Tab linezolid 600mg PO OD
tab ultracet PO OD
tab atorvastatin 20mg 
Tab ecospirin 325mg PO/ STAT
Inj.Atropine 0.6mg IV/STAT
Inj.HAI s/c TID
Left lowerlimb elevation
Monitor Temp,PR,BP,SpO2 hourly
GRBS monitoring
liquid diet

28/10/23
Inj.Meropenem 1gm IV BD
Inj.Metrogyl 500mg IV TID
Inj.Pan 40mg PO OD
Tab linezolid 600mg PO OD
Inj.Zofer 4mg IV/TID
tab ultracet PO OD
tab atorvastatin 20mg 
Tab ecospirin 325mg PO/ STAT
tab.Clopidogrel 75mg PO/OD
Inj.Atropine 0.6mg IV/STAT
Inj.HAI s/c TID
Left lowerlimb elevation
Monitor Temp,PR,BP,SpO2 hourly
GRBS monitoring
liquid diet

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