62M with chief complaints of blackish discoloration of left great toe

- October 28, 2023

Hi!! This is Vijaya ratna,9th semester student.

This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan

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A 62 year old male Patient came to GS OPD with c/o blackish discoloration of left great toe since 15 days

HOPI

patient was apparently asymptomatic 3 months back then developed a blister on the left great toe which got ruptured and developed into a non healing ulcer and the infection has gradually increased

15 days back pt came to hospital with blackish discolouration of left great toe

No H/o fever

No H/o itching

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

PAST HISTORY

20 years back patient suddenly developed blurring of vision and rushed to local hospital, found out that he had diabetes

N/k/c/o HTN,ASTHMA, CVA,TB

patient had similar complaints in the past 1 year back of right great toe and got it amputated.

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

PERSONAL HISTORY

Normal appetite

Mixed type of diet and irresistible eating of sweets.

Regular bowel and bladder movements

Frequent urination in the night around 4-5 times

There are no allergies of food or any drugs

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

TREATMENT HISTORY

2 yrs back he started taking insulin for diabetes.

1 yr back got his right great toe amputated

FAMILY HISTORY

His brothers have diabetes

VITALS

Temp: 98.7

Spo 2: 98%

Bp: 110/60 mm of hg

RR: 16cpm

GENERAL EXAMINATION

Pt is conscious,coherent and cooperative

well built and malnourished

pallor : present

No signs of icterus,cyanosis,clubbing,pedal edema, lymphadenopathy

Mid arm circumference 28 cm

Mamc: 23.6 mm

Triceps skinfold thickness:14mm

Abdominal girth: 98cm

Fvf ratio: 98-23.6 =4.15

LOCAL EXAMINATION OF LEFT FOOT

INSPECTION

dry shriveled mummified left great toe with blackish discolouration over dorsum of foot present upto base of great toe and medially upto midtarsal bone

Ventrally upto midtarsal

Scaly skin present

Scanty serous discharge present

Ulcer present over at base of left greater toe of 4*2 cm size

Irregular margins

Floor is covered with slough

No line of demarcation

PALPATION

all inspectory findings confirmed

No local rise of temperature

Base of ulcer is underlying bones and muscles

Tenderness not present