GENERAL MEDICINE E-LOG 5

 HI,Iam Harichandana of 3rd sem medical student.This is an online elog book to discuss our patients health data after taking his consent.This also reflects patient centred online learning portfolio


A 35 yr old male resident of samsthan narayanpoor came to casuality with ulcer over right foot since 4 days

HISTORY OF PRESENT ILLNESS:

patient was apparently asymptamatic 4 days back then he developed ulcer over right foot medial aspect which gradually progressed to present size,assosiated with pus discharge.

burning micturition after removal of urine catheter

cough since 4 days 

no case of fever and trauma

HISTORY OF PAST ILLNESS:

Patient met with accident 3 years back by falling from bike then he got injury to his right leg 

diagnosed with diabetes 8yrs and he is on regular medication

patient might stepped on a sharp object without knowing leading to the ulcer 

PRESENT:

Blackish discoloration of right foot

edema present on both legs

temperature of right increased than left

pitting edema present 

pulses-not palpable due to edema

discharge is present

unable to move right leg

left normal movemt with pitting edema

PHYSICAL EXAMINATION:

 


 SYSTEMIC EXAMINATION:


ANASTHESIA MEDICATION:


PROVISIONAL DIAGNOSIS:

diabetic foot

INVESTIGATIONS OFFERED:

Surgical profile

x ray right foor AP and LATERAL

PLAN OF CARE:

Debridment










  MEDICATION CHART:





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