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CASE 1
SUBJECTIVE:

Patient name : Mr. Venkatesh

Age : 59 years

Gender : Male

I. P. No : 1374

Ward : MSI

Date of Admission : 03/07/2019

Chief Complaints : C/o non-healing wound over right heel x 1 year

Past medical history : K/C/O diabetes from past 6 months

Past medication history : Glimepiride(1mg) and metformin(500mg) (not adhered to

medication)

Family history : Nil

Social history : Patient is an alcoholic (from the age of 20 yrs.)

Allergies (drug) : N/K/A

Allergies (food) : N/K/A

OBJECTIVE:

O/E:

BP - 160/100mmHg
PR - 90/min
RR - 16/min
Temp - 98°F
CVS - S1S2+
RS - BAE+
CNS - NFND
P/A - Soft
SpO2 - 95% at RA
L/E - 4cm x 4cm on right heel(ulcer)
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Laboratory parameters altered:

Investigation Patient Value Normal Value

Hb 10.6g/dl 14-18g/dl

HCT 35.6% 39-49%

MCV 73.7m3 76-100m3

MCH 21.9pg/cell 27-33pg/cell

MCHC 29.8g/dl 33-37g/dl

RBS 207mg/dl <200mg/dl

ASSESSMENT:

Diabetic foot ulcer/ SHTN

PLAN:

Drug(s) prescribed on admission (Day 1)

Sl.no Drug(s) Name Dose Frequency

DIL
Diabetic diet
Plenty of oral fluids
Inj. Cefotaxime 1g IV BD
Inj. Metronidazole 500mg IV TDS
Inj. Ranitidine 50mg IV BD
Tab. Paracetamol 500mg BD
BCT 30.5mg BD
Tab. Amlodipine 2.5mg BD

Daily wound cleaning and dressing

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Date Day O/E Patient complaints Drug(s) Prescribed Dose Frequency

4/7/1 02 160/110mmH L/E: DIL

9 g Diabetic ulcer Diabetic diet
PR: 82b/min along Plenty of oral fluids
RR: 20/min Slough + Inj. Cefotaxime 1g IV BD
TEMP: 98.4°F Left leg varicose Inj. Metronidazole 500mg IV TDS
vein Inj. Ranitidine 55mg IV BD
PPBS: Tab. Paracetamol 500mg BD
200mg/dl BCT 30.5mg BD
FBS: Tab. Amlodipine 2.5mg BD
126mg/dl Tab. Metformin 500mg BD
Tab. Glimepiride 1mg BD

Compression
stockings

03 L/E: DIL
5/719 Pt. conscious, Right foot Diabetic diet
oriented, diabetic ulcer Plenty of oral fluids
afebrile Inj. Cefotaxime 1g IV BD
BP: Inj. Metronidazole 500mg IV TDS
180/110mmH Inj. Ranitidine 55mg IV BD
g Tab. Paracetamol 500mg BD
PR: 80b/min BCT 30.5mg BD
RR: 22/min Tab. Amlodipine 2.5mg BD
TEMP: 98.4°F Tab. Metformin 500mg BD
Tab. Glimepiride 1mg BD

SRD
04
6/7/19
Inj. Cefotaxime 1g IV BD
Pt. conscious, Inj. Metronidazole 500mg IV BD
oriented, Tab. Diclofenac 50mg BD
afebrile, no Tab. Ranitidine 150mg BD
pallor TAB. Amlodipine 2.5mg 2-0-2
BP: Tab. Atenolol 50mg BD
160/100mmH Tab. Glimepiride 1mg BD
g Tab. Metformin 500mg BD
PR: 86b/min
RR: 24/min
TEMP: 98.2F
CVS: NAD
RS: NAD
P/A: soft, BS
+
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05 a/c/o SRD
Diabetic foot Inj. Cefotaxime 1g IV BD
7/7/19 with varicosity Inj. Metronidazole 500mg IV BD
Pt. conscious, on left leg Tab. Diclofenac 50mg BD
oriented, Tab. Ranitidine 150mg BD
afebrile TAB. Amlodipine 2.5mg 2-0-2
BP: Tab. Atenolol 50mg BD
170/100mmH Tab. Glimepiride 1mg BD
g Tab. Metformin 500mg BD
PR: 86b/min
RR: 20/min
TEMP: 98.4F
CVS: S1S2+
RS: BAE+
CNS: NFND
P/A: soft
PPBS:
213mg/dl
FBS:
06 141mg/dl a/c/o Cap. Amoxicillin 250mg 2-2-2
L/E: wound Non-healing Tab. Paracetamol 500mg 1-0-1 x3days
8/7/19 healthy ulcer with 1-0-1
Tab. Glimepiride 1mg
varicosity Tab. Metformin 500mg 1-0-1
Pt. conscious, Tab. Amlodipine 2.5mg 2-0-2
oriented, Tab. Atenolol 50mg 1-0-1 to
afebrile continue all
BP:
150/90mmHg
PR: 84b/min
Advice:
RR: 22/min
TEMP: 98.4F • Apply Patient discharged
CVS: S1S2+ crepe
RS: B/L bandage 6
NVBS+ inch
CNS: NFND • To do
P/A: soft regular
L/E: no active dressing
pus/ slough at nearby
mass GH
healing • Diabetic
diet with
salt
restriction
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