A 68YRS WITH ALTERED SENSORIUM UNDER EVALUATION SECONDARY TO ?SEPTIC ENCEPHALOPATHY WITH TYPE 2DM SINCE 25YRS WITH HTN SINCE 20YRS WITH LEFT 3RD TOE NON HEALING ULCER

This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians signed informed consent.

Here we discuss our individual patient problems through series of inputs from available Global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.

This Elog also reflects my patient centered online learning portfolio.
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 a diagnosis and treatment

Chief complaints::

A 68yr Rtc bus driver came with
C/o ulcer over the left foot since 1month
Blackish discolouration of left 3rd toe since 15days
Burning micturition  since 15days
Altered sensation since 3days

History of present illness::

Patient was apparently asymptomatic 1month ago then he had developed pain in left foot region ,insidious in onser gradually progressive ,relieved upon hanging leg along bedside 
Next patient developed BLISTER (white coloured) over 3rd toe 1month ago ,it ruptured eventually with very scanty discharge and developed to ulcer  presented over pulp of 3rd toe ,for which patient treated by local rmp .
Then patient developed blackish discoloration over left 3rd toe associated with pricking type of pain ,continous  type ,radiating towards left leg since 2 days.
H/o burning micturition since 15 days
No H/o Trauma /exposure to severe cold or hot temperature 
No h/o fever,vomitings ,loose stools ,pain abdomen ,giddiness 
C/o altered sensorium since 3days H/o irrelevent talk,not able to recognize adults 
Past history::

Known case of DM -2 since 25yrs on Human mixtard 10u od
K/c/o HTN wince 20yrs on Tab.Telma -H po/od
H/o similar complaints 12yrs ago

Not a known case of TB,cva,cvd,thyroid disorders,epilepsy
Family history::
 Not significant 

Personal history::
 
Diet: mixed
Sleep ::   adequate
Appetite:: normal 
Bowel and bladder:: regular
Addictions::Nil

General examination::

After taking consent patient examined in a well lit room
Patient was conscious coherent cooperative 
Well oriented to time ,place ,person
Moderate built, nourishment moderate

pallor present 
No icterus
No Lymphadenopathy
No cyanosis
No clubbing
 No Edema 


Vitals

Temperature::99.3f
PR-110bpm
Bp-150/90 mmhg
RR--18cpm

Local examination::

Blackish discolouration of left 3rd toe 
Line of demarcation present 
Redness over dorsum of foot left foot present 
Skin appears to be shiny,thin and edematous upto ankle region 

On palapation:: 
Local rose of temp present over left leg 
Tenderness present over dorsum of left foot upto below knee region 
Wet gangrene of left 3rd toe present 
No crepitus,no active discharge
All movements normal

Peripheral pulsation::
                    Right.              Left
Dpa.             +.                     +
Ata.              +.                      +
Pta.              +.                      +
Popliteal artery +.               +


DISARTICULATION OF LEFT 3rd TOE 





Respiratory system::
Inspection::

B/L symmetrical 
Trachea appears to be central
Supraclavicular and infraclavicular hallowing absent
Expansion of chest equal on both sides
No crowding of ribs 
No drooping of shoulder
Wasting of muscles absent
No scoliosis ,kyphosis
No sinuses,scars,engorged veins

Palpation::

No local rise of temperature
All inspectory findings confirmed
Trachea central
Apex beat felt in 5th ICS in mid clavicular line

Percussion::

Direct : over clavicle and manubrium sternum
Indirect ::::Resonant 

                                             
Auscultation::

 B/L air entry present 
On auscultation:: NVBS heard 


PER ABDOMEN::

Inspection..

Shape of abdomen...scaphoid
Umbilicus..inverted,central located
No sinuses or scars on abdomen

Palpation::

No rise in temperature
No Tenderness present
No palpable mass 
No free fluid
Liver not palpable
Spleen not palpable

Percussion::

Dull note on right upper quadrant
No fluid thrill
No shifting dullness

Auscultation::

Bowel sound heard:

Cardio vascular system:
Jvp -not raised
Apex beat felt in 5th ICS in mid clavicular line
S1s2 heard
No murmurs

Central nervous system::

Gcs E4V5M6
Power     Rt.      Lt
 ul.         5/5.    5/5
Ll.           5/5.     5/5
Tone        N.         N
ul.            N.         N
Ll.            N           N
Reflexes
 Biceps.     2+.       2+
Triceps.      1+.        1+
Supinator.     1+.       1+
Knee              2+.       2+
Ankle              1+.       1+



Investigations::

Chest xray PA view ::
Usg abdomen and pelvis ::




Provisional diagnosis::


ALTERED SENSORIUM UNDER EVALUATION SECONDARY TO ?HYPOGLYCEMIA?SEPSIS WITH TYPE 2DM SINCE 25YRS WITH HTN SINCE 20YRS WITH LEFT 3RD TOE NON HEALING ULCER



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