62yr old male with blackish discoloration of great toe,( post op bradycardia)

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.
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 yrs old pt came to GS opd with blackish discoloration of left great toe since 15 days.


 HOPI
pta was apparently asymptomatic 3 months back and developed a blister on the left great toe and that has ruptured and formed an ulcer which is not healed and that  infection has gradually increased.
15 days back pt came to hospital with blackish discoloration of that great toe. 
No h/o any fever
No h/o itching
No h/o vomitings ( at the time of joining) 

PAST HISTORY:

Patient had similar complaints in the past 1 yr back for the right great toe and got amputated other outside hospital. 
20 yrs back patient suddenly develoed blurring of vision for some time and rushed to a local hospital and found out  that he had diabetes. (Diabetic since 20yrs ) 
Not a k/c/o  HTN, ASTHMA, CVA, TB. 

PERSONAL HISTORY:
Normal appetite
Mixed type of diet and irresistible eating of sweets. 
Regular bowel and bladder movements
There are no allergies for food or any drugs 
Addictions :  patient used to drink and smoke daily in the past  for 40 yrs and stopped10yrs back. 


TREATMENT HISTORY:

50yrs back he got amputated his ring finger upto distal Interphalangeal joint because of trauma to that finger. 
Since 20 yrs he is on oral metformin for diabetes. 
2 yrs back he started taking insulin for diabetes. 
1 yr back got amputated his right great toe. 



FAMILY HISTORY: 

His brothers have diabetes

VITALS 
 Temp: 98.7
 Spo 2: 98%
 Bp: 110/60 mm of hg
 RR: 16cycles / min
 Pulse: 66 bpm

GENERAL EXAMINATION:
Pt is well built and malnourished , well cooperative coherent and coordinative. 

pallor : present
Icterus : absent
Cyanosis : absent
Clubbing : absent

Koilonochia : absent

Lymphadenopathy :absent
Pedal edema : mild 

Mid arm circumference 28 cm
Mamc: 23.6 mm
Triceps skinfold thickness:14mm
Abdominal girth: 98cm
Fvf ratio: 98-23.6 =4.15


SYSTEMIC EXAMINATION
Cvs
S1S2 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 localised raise of temp. 
No scars and sinuses
No organomegaly
Bowel sounds heard


LOCAL EXAMINATION:
Left leg
After rays amputation. 
Healthy granulation tissue is seen. 
Margins are regular.
 No bleeding. 
INVESTIGATIONS:
Ecg
25/10/2023
26/10/2023

27/10/2023
30/10/2023
26/10/2023
RFT
1) 30/10/2023
2) 25/10/2023
 GLYCATED HAEMOGLOBIN
Blood sugar fasting
28/10/2023

 Random Blood sugar
Serological tests

 ABG
 LIVER FUNCTION TEST

 APTT
BLEEDING and  CLOTTING TIME

Prothrombin time
Troponin 
Complete urine examination
Liver function test
BLOODGROUPING AND RH TYPING
ULTRASOUND :
25/10/2023
2D ECHO
27/10/2023

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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