56/M with ulcer on the right foot

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Case : 

A 56 year old male had come to the OPD with chief complaints of ulcer on the right foot since 18 days and rat bite on the right index finger since 10 days. 

History of Present Illness : 

Patient was apparently asymptomatic 18 days ago, then he developed a painless blister on the medial aspect of his right foot which eventually burst to form an ulcer. 

For the first few days, the patient turned a deaf ear to the ulcer thinking it would get healed on its own. On Thursday (14th of July, 2022), on his way back home from work, he noticed watery discharge oozing out of the ulcer which was non foul smelling and non blood stained. After washing his foot, he noticed the skin over the ulcer chipping off. This was an alarming sign that had made him come to the hospital on Friday (15th of July, 2022). 

10 days ago, in his sleep a rat bit him on the right index finger. Until the next morning, he had not noticed the bite. 

Presence of ulcer on the plantar aspect of the left hand. 

Daily Routine : 

The patient is a lorry driver by occupation. 

He wakes up at 5 AM in the morning and has his breakfast by 8 AM and leaves for work. 

Usually has his lunch by 1 PM and Dinner by 8 PM. He has been drinking alcohol (90ml) everyday for the past 40 years now. 

Past History : 

Not a known case of Hypertension, Asthma, Epilepsy, Tuberculosis, Thyroid disorders. 

The patient is a known case of diabetes type 2 since 7 years. 

7 years ago, a blister was formed on the lateral malleolus of his left foot which he took no notice of. 4-5 days later, he started feeling giddy, tired and had downtime in his work. So he had been taken to the hospital and had been diagnosed with diabetes. He’s been on medication ever since. 

Personal History :

Sleep : Normal 

Diet : Mixed 

Appetite : Normal 

Bowel and Bladder Movements : Regular 

Addictions : Patient consumes alcohol everyday since 40 years. Patient used to smoke beedi (1 pack a day) and cigarette (1 pack a day) since the age of 12. He has quit smoking since 2 years. 

Family History : 

No similar complaints 

General Examination: 

 

Pallor - absent 

Icterus - absent 

Cyanosis - absent 

Clubbing of the fingers - absent 

Lymphadenopathy - absent 

Pedal Oedema - absent 





Vitals : 

Temperature - 98.4 degree Fahrenheit 

Pulse - 86 bpm 

Respiratory rate - 16 cpm

BP - 110/70 mm of Hg

Systemic Examination : 

CVS - S1 and S2 were heard 

Respiratory system - bilateral vesicular breath sounds are present 

Abdomen - soft and non tender 

CNS Examination: 

Deep reflexes - 

       

    Plantar Reflex - 

Sensory Motor - 

        Crude Touch -

     Fine Touch - 

       

              Pain - 

Investigations :

RBS - 

[20/07/2022] 8 AM - 198 mg/dl ; 2 PM - 158 mg/dl ; 8 PM - 358 mg/dl

[21/07/2022] 8 AM - 193 mg/dl ; 2 PM - 384 mg/dl ; 8 PM - 282 mg/dl 

[22/07/2022] 8 AM - not taken ; 2 PM - 185 mg/dl ; 4 PM - 240 mg/dl ; 8 PM - 

Provisional Diagnosis : 

Diabetic ulcer on the right foot 

Rat bite on right index finger 

Treatment : 

Tab Glimi M1 OD

Tab Glimi M2 OD

Inj H Actrapid S.C GRBS 6th hourly 

T Bact Ointment OD

T Fucid Cream OD