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

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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.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 
 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
B/l pedal edema present upto distal half of leg
Dorsalis pedis and anterior tibial not present
Pulse feeble in posterior tibial

RIGHT FOOT
SYSTEMIC EXAMINATION
CVS
S1,S2 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 local raise of temp. 
No scars and sinuses
No organomegaly
Bowel sounds heard

INVESTIGATIONS
25/10/23
ECG
Ultrasound
26/10/23
27/10/23
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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