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TikurAnbessa Hospital Addis Ababa

Name: BalechaDesalegnAge: 65 Sex: M Occupation: Waiter Religion: Orthodox Christian

Address: TekleHimanot, Addis AbabaDate of Admission: April 15 2012Ethnicity: Oromo

Department: Internal Medicine Ward: B-8 Bed No:814.5Marital Status: Married

Date of Clerking: April17 2012Source of History: The Patient

Chief Complaint

Left foot ulceration of 1 month duration, Cough 1 week duration

History of Present Illness

This is a known Diabetic patient for the past four years who has been taking oral hypoglycemic agent 2/day
for the past three years and insulin 2/day for the last one year. He has a regular follow up here in Black Lion
Hospital.

He was relatively healthy until three months ago at which time he started to experience a gradual onset of
left calf stabbing pain which radiated to his toes and numbness of both feet. Both symptoms were
intermittent occurring mainly when walking and relived by massaging of the legs, sitting and lying down.
The numbness started to spread upwards from the toes and involved the knees after 2 weeks. At the same
time he started experiencing a burning sensation of the left sole of the foot. It was constant but increased
in intensity when walking while painkillers and massaging in cold water eased the pain.

Around one month later the patient noticed bilateral swelling of the feet and a small black discoloraton
the plantar surface of the left big toe. The swelling involved up to the knee but subsided after 4 days of
constant massaging while the black discoloration of the toe increased in size and ulcerated one week later.
The ulcer was small at first but within the following two weeks it enlarged constantly involving the whole
plantar surface of the left big toe.

Following this he came to Black Lion Hospital. Since no bed was available he was scheduled to come on
April 26 (three weeks later) and was sent home.

One week before present admission he started experiencing a sudden onset of intermittent fever
accompanied by sweating, chills, palpitations, numbing global headache and dull abdominal pain(relieved
by eating). These happened both day and night, mostly occurring at 11am, 6pm and 10pm sometimes
awakening him from sleep. He also experienced non-productivecough occurring mostly at night which was
exacerbated by deep breathing. In addition he had loss of appetite, easy fatigability, excessive thirst,
increase in the volume and frequency of urination both day and night, waking three to four times a night

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to urinate. He also had blurring of vision on the left eye which appeared a week ago with the other
symptoms.

Following this he came to black lion hospital emergency OPD and was admitted to B8 ward on the same
day.

The patient has a history of foot ulcer two years ago on the same toe. He went to RasDesta Hospital and
was advised to have an amputation of the toe but he refused and was discharged. But the patient claims
that after two weeks of washing the foot with salt water the ulcer subsided and disappeared.

He has history of blurring of vision four years back at the time of diagnosis of the diabetes. Laser eye
surgery was done on the left eye but the patient refused for the right eye due to discomfort. Following that
the eye sight on the left eye corrected but on the right eye, the blurring of vision and shadowing progressed
to total blindness.

He also had a history of hypertension diagnosed at the same time as the diabetes and has been taking
unspecified oral medication daily since then.

No leg trauma or history of wearing ill-fitting shoes. No chest pain or shortness of breath. No history of
chronic cough or contact with a chronic cougher. No polyphagia, pruritus, mental confusion, aggression,
convulsion or loss of consciousness. No hair loss, constipation, dysphagia, fullness, nausea or vomiting. No
diarrhea, difficulty in micturition, fecal or urine incontinence. No red discoloration of urine, dysuria, urinary
urgency or hesitancy. There is no family history of diabetes, hypertension, allergy, or sudden death.

The patient was 72 kg before the start of the illness. He never weighed himself afterwards but has showed
marked reduction in his weight in the last three months. There is no color change noted by the patient and
he came to black lion hospital supported by his family.

Previous Admission

None

Past Illnesses

No chicken pox, mumps, small pox or any other childhood diseases.

He had surgery on the inside of t

e right leg following diagnosis of varicose vein over thirty years ago. Symptoms improved immediately.

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No trauma, psychiatry problems or drug allergy.

Functional InquiryH.E.E.N.T

Head:SEE HI. No trauma.

Ears:No loss of hearing, discharge, earache, vertigo or tinnitus

Eyes:SEE HPI. No strain, lacrimation, or itching

Nose: No epistaxis or discharge.

Mouse and throat:Nodental pain, bleeding from the gums, sore throat. His tonsils were removed
by a local expert around thirty years back.

Glands:No enlarged masses over the neck, axilla or groin. No heat or cold intolerance.

Respiratory System:SEEHPI.Noexpectoration,hemoptysis, wheezing or stridor.

Cardiovascularsystem:SEEHPI.No orthopnea or paroxysmal nocturnal dyspnea.

Gastrointestinal system:SEE HPI. No dysphagia, tarry or clay colored stool.

Genitourinary system:SEE HPI. No flank pain, dribbling or pyuria.

Integumentary system:SEEHPI.Moist skin, no rashes, changes in hair distribution.

Allergy:Noasthma,drug sensitivity or food allergy.

Locomotory system: No bony deformities, no joint pain.

Central nervous system: SEE HPI.

Personal History

He was born in Fiche, Oromia zone where he lived until he was around 15 years old following which he
came to Addis Ababa. He had a healthy childhood and was an active boy who liked playing with his friends.
Like his parents he never went to school but he is able to read and write.

He was a soldier for 4 years around 40 years back (he never sustained any injuries). After that he was
unemployed but found a waitering job 2 years later. He is still a waiter working at the same place for 38
years.

He has no history of tobacco or chat abuse but he used to drink alcohol around twice a week till
intoxication since his late twenties. He stopped drinking after diagnosis of diabetes four years back.

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He has been on no sugar and minimal salt diet for the past 4 years after diagnosis of diabetes and
hypertension.

He is currently married and has been for more than thirty five years. He has seven children all are healthy
and living well.

Family History

Father and mother:His mother died 2 years ago at age 85 due to natural causes. He never knew his father.

Siblings: He has one sister. She is healthy and living well.

Family Diseases: SEE HPI.

Physical Examination
General Appearance

The patient appears to be alert and is fully cooperative. He is lying on his back.He appears to be slightly
worried but doesn’t seem to be depressed. He isn’t malnourished and doesn’t seem to be in respiratory
distress.

Vital signs

BP:130/90mmHg, right arm, supine positionPulse:84/min., radial artery, regular, full volume

120/80 mmHg, right arm, standing position RR: 36/min, shallow, regular rhythm

T0:36.90c, axillary, morning Weight: ? Kg

Height: 1.68 Meters

H.E.E.N.T

Head: Normal size, shape and hair distribution, No scar.

Ears: Normal contour of pinna.Clear external ear canal.

Eyes: Normal eyebrows. No per-orbital edema, ptosis, exophthalmoses or strabismus. The conjunctivaeare
pink. The scleraearenoticteric.Thepupil are black. No funduscopic examination was done.

Nose: The nasal septum is not deviated. There is no polyp or unusual discharge.

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Mouse and throat:Thelips show no fissure, ulceration or herpes. The gums areintact and show no
ulceration. The left upper molar, left lower molar and premolar are cracked. The left last upper and lower
premolar are carious. There are no extractions, dentures or filling. The tongue is pink, doesn’t show any
atrophy. The tonsils are intact but the uvula is removed.

Lymphatic and glandular system

There are no enlarged lymph nodes over the occipital, posterior and pre auricular, anterior and posterior
cervical, sub-mandibular, sub-mental, supra-clavicular,axillary,inguinal and epithrochlear areas.

The thyroid is not enlarged. No tremor or lid lag.

Respiratory System

Inspection: There is no cyanosis or clubbing or the finger nails.The palms arenotpale. Breathing is shallow
butis of regular rate. The chest is symmetrical. There are no deformities, surgical scars, visible
pulsation or dilated vessels.

Palpation: Thetrachea is slightly deviated to the right. There is no tenderness overtheentirechest. The
total circumferential chest expansion is 1.5 cm along the nipple line on deep inspiration. Tactile
fremitus is normalover the entire lung field. Chest expansion is symmetrical.

Percussion:Both the rightand left chest are resonant. Diaphragmatic excursion is 1 cm.

Auscultation:The breath sounds are vesicular over the entire the lung field. No wheezing, crepitations,
stridor or pleural friction rub.

Cardiovascular system

Arteries: BP and pulse (see under vital signs). There is no hardening of the vessel wall. Pulse volume can be
tabulated as follow:

Carotid Axillary Brachial Radial Femoral Popliteal PT DP

Right +++ ++ ++ ++ +++ ++ ++ ++

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Left +++ ++ ++ ++ +++ ++ ++ -

No radio-femoral delay detected.

No bruit over the carotid or femoral artery.

Veins: There are distended veins over the anterior and medial sides of the left distal lower limb. No
distended veins over the neck and chest wall.

JVP observed at an inclination of 450 is 3 cm above the angle of Louis.

No Hepato-jugular reflex.

Precordium

Inspection: There is no precordial bulge. The precordium is Quiet. The apical impulse isnotvisible.

Palpation: The point of maximum impulse isnotfelt.The heart sounds aren’t palpable.There is no
parasternal or apical heave. There is no thrill.

Auscultation: Both heart sounds are normal over the valvular areas. There are no added heart sounds
(split, gallop, ejection click, opening snap) or murmurs.

Gastrointestinal System

Inspection:The abdomen is flat, symmetrical and moves with respiration.Theflanks arenotfull. There are no
surgical scars,massesordilated veinsoverabdomen. The umbilicus is inverted. Hernia sites are free. No
visible pulsation or peristalsis. No caputmedusae.

Auscultation: The bowel sound is normo-active. There is no bruit over renal artery, abdominal aorta or liver
areas.

Palpation:

 Superficial palpation: There was no muscle spasm, or superficially palpable mass. There was also
no direct or rebound tenderness.

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  Deeppalpation:The liver wasnotpalpable below the right costal margin. The spleen isalsonot
palpable.

Percussion: There is no shifting dullness, fluid thrillorflank dullness. The total vertical span of the liver along
the right mid-clavicular line is8 cm.

Integumentary System

There is a crusted, ulcerated black lesion on plantar surface of the left big toe. There is area of
hyperpigmentation starting from the anterior and medial sides of the left distal lower limb all the way to
the toes. The skin over the anterior surface of the left foot is dry but warm. There is no abnormal hair
distribution. The nails don’t show spooning orclubbing.The skin is warm with no rash or scars.

Locomotory System

There is left calf muscle tenderness with radiation to the left toes. There is no spasm. There is no bone
deformity or tenderness. There is no stiffness of the joint.

Nervous system

Mental Status:

The patient is conscious, fully cooperative and doesn’t seem to be depressed.

He knows what day it is, where he is and what his name is. Orientation

He remembers what he ate for breakfast. He also remembers where he used to live. Memory

He speaks in a normal voice tone and there is no hesitancy or gaps in the flow and rhythm of his words.
Speech

He denies any hallucinations or delusions.

Cranial Nerves:

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N-I: Smells alcohol via each nostril.

N-II: He can differentiate 2 fingers at about 6 meters by the left eye but he can’t differentiate 2 or any
fingers from any distance by the right eye. (Visual Acuity)

He sees waggling of finger approximately 800 from axis of eye on the left eye but he can’t see
waggling of fingers at any axis of the angle of the right eye. (Visual Fields)

He differentiates green and red colors on the left eye but the colors aren’t visible by the right eye.
(Color Appreciation)

N-III, IV & VI: The eyes can move in all directions. There is no nystagmus or diplopia. The pupils are round,
regular in outline and equal in size. But they don’t react to light directly and consensually.

N-V:Heidentifies light touch and pin prick over the mandibular, maxillary and ophthalmic areas of the face.
He closes his eyes at the touch of the cornea with a cotton swab on both eyes. Contraction of the temporal
and masseter muscles is symmetrical and strong.

N-VII: The face is symmetrical at rest and during voluntary movements (smiling, raising the eye brows). He
can close both eyes equally and forcefully.

N-VIII: He hears rubbing of the fingers on both ears.

N-IX & X:The soft palate rises in the midline when saying ‘ah!’

N-XI:TheSternocleidomastoid and trapezius muscles contract on turning the head and on shrugging the
shoulder against resistance, respectively.

N-XII:The tongue protrudes in the midline and shows no fasciculation or atrophy.

Motor:

 Musclebulk: There is no muscle bulk reduction in all extremities and there is also no bulk difference
between the left and the right sides. There is no spontaneous as well as induced fasciculation.
 Muscle toneandpower.

TONE POWER
Upper Lower Upper Lower
Right Normo-tonic Normo-tonic 5 5

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Left Normo-tonic Normo-tonic 5 4

0 – no active contraction 1 - flickering movements 2 - movement in horizontal axis

3 - movement against gravity only 4 - movement against gravity + mild resistance 5 - normal power

Coordination:

Finger to nose, heal to shin and rapid alternating movement of the arm were done without any
abnormalities.

Pronator Drift test was negative.

Reflexes:

 Superficial reflexes:Abdominal reflex is absent both in upper and lower quadrants.Corneal reflex is
intact in both eyes.Plantar reflex is equivocalon both sides.
 Deep tendon reflexes:

Biceps Triceps Supinator Patellar Ankle

Right ++ ++ + - -
Left ++ ++ + - -

 Clonus: No clonus

Sensory:

 There is a loss of sensation of light touch and painover the dorsal and plantar surface of the left
foot below the ankle and all five toes of the right foot. There is also loss of temperature
sensation over the dorsal and plantar surface of the left foot and the lateral four toes of the right
foot. He identifies light touch and pin prick over the upper extremities and trunk.
 He is able to recognizedifferent movements of the big toe of the right foot with his eyes closed but
not the big toe of the left foot.(Position sense)
 Vibration sense was not assessed due to lack of Tuning Fork.
 He appreciates the form of a key by means of only touch (Stereognosis)
 He recognizes writings of different numbers on his palm (Graphesthesia)
 He is able to differentiate 2 pin pricks upto 4 mm apart over the fingertipsof both right and left arm
(2 point discrimination).

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Meningeal Sign:

 There isnoneck stiffness.

 Kernig's Sign is negative.
 Brudzinski's Sign is negative.

Summary of problems
 Subjective summary:
o Known diabetic patient for 4 years currently on insulin injections
o left calf stabbing pain
o numbness of both feet with stocking type of spread
o burning sensation of the left sole of the foot
o bilateral swelling of the feet which disappeared after 5 days
o black discoloration and ulceration on the plantar surface of the left big toe
o intermittent fever accompanied by sweating,
o chills
o palpitations
o numbing global headache
o dull abdominal pain
o non-productive cough
o loss of appetite, weight loss
o easy fatigability
o polydipsia, polyuria, nocturia
o visual defect mainly on right eye
o history of previous foot ulcer on the same toe
o history of hypertension of 4 years duration

 Objective Summary:
o Postural Hypotension
o Tachypnea with shallow breathing
o Carious tooth

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 o Decreased chest expansion
o Dorsalispedis artery of the left leg not palpable
o Distended veins over the anterior and medial sides of the left distal lower limb
o Hyperpigmentation starting from the anterior and medial sides of the left distal lower limb
all the way to the toes.
o Dry skin over the anterior surface of the left foot
o Dry foot ulcer
o Decreased visual field on left eye and complete absence of visual field and acuity on the
right eye
o Loss of pupillary reaction to light directly and consensually
o Power is 4/5 in the left lower limb.
o Abdominal reflex is absent. Plantar reflex is equivocal bilaterally.
o Patellar and ankle reflex are 0/4 bilaterally.
o Loss of position sense of the left big toe
o Loss of sensation of light touch and pain over the dorsal and plantar surface of the left foot
below the ankle and all five toes of the right foot. Loss of temperature sensation over the
dorsal and plantar surface of the left foot and the lateral four toes of the right foot.

Differential Diagnosis
 Diabetic retinopathy
 Peripheral neuropathy
 Diabetic foot ulcer
 Pneumonia
 Madura Foot

Discussion of Differential Diagnosis

 Diabetic Retinopathy: is one of the commonest chronic complications and one of the leading
causes of blindness between the ages of 20 and 74 in the developed countries. Individuals with DM
are 25 times more likely to become legally blind than individuals without DM. Symptoms include
difficulty of reading, blurring of vision and shadowing which may later on progress to total
blindness; of which the last two are consistent with this patient. Plus the physical findings of the

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 left and right eye are in accordance with this chronic complication. Duration of DM, degree of
glycemic control and presence of hypertension are the best predictors and risk factors in the
development of retinopathy.

 Peripheral Neuropathy: Diabetic neuropathy occurs in 50% of individuals with long-standing type 1
and type 2 DM. It may manifest as polyneuropathy, mononeuropathy, and/or autonomic
neuropathy.

o Polyneuropathy is the commonest neuropathy, characterized by distal symmetrical,

predominantly sensory impairment which manifests with tingling sensation, numbness,
burning sensation, diminished perception of vibration sensation distally, 'glove-and-
stocking' impairment of all other modalities of sensation, and loss of tendon reflexes in the
lower limbs; all are present in this patient.
o Mononeuropathy is a dysfunction of isolated cranial or peripheral nerves. It is less common
than polyneuropathy in DM and presents with pain and motor weakness in the distribution
of a single nerve. Mostly presents with diplopia and bell’s palsy which are both absent in
this patient.
o Autonomic neuropathy may manifest with postural hypotension, dry skin, pupillary
irresponsiveness to light, dysphagia, abdominal fullness, nausea, vomiting, difficulty in
micturition, erectile dysfunction, etc.; of which the first three are present in this patient.

As with other complications of DM, the development of neuropathy correlates with the
duration of diabetes and glycemic control. Additional risk factors are BMI (the greater the BMI,
the greater the risk of neuropathy), smoking, the presence of cardiovascular disease, elevated
triglycerides, and hypertension.

 Diabetic Foot Ulcer: The peripheral sensory neuropathy interferes with normal protective
mechanisms and allows the patient to sustain major or repeated minor trauma to the foot, often
without knowledge of the injury. Disordered proprioception causes abnormal weight bearing while
walking and subsequent formation of callus or ulceration. Motor and sensory neuropathy lead to
abnormal foot muscle mechanics and to structural changes in the foot (hammertoe, claw toe
deformity, prominent metatarsal heads, Charcot joint). Autonomic neuropathy results in anhidrosis
and altered superficial blood flow in the foot, which promote drying of the skin and fissure
formation. Peripheral arterial disease and poor wound healing impede resolution of minor breaks
in the skin, allowing them to enlarge and to become infected. The symptoms and signs of foot ulcer
are numbness and burning, aching pain, swelling, darkening and cold extremity. Most of the
predisposing factors, signs and symptoms are present in this patient which makes this complication
very likely. Risk factors for foot ulcers include: male sex, peripheral neuropathy, history of previous
ulcer or amputation diabetes, diabetes >10 years' duration, abnormal structure of foot (bony
abnormalities, callus, thickened nails), peripheral arterial disease, smoking, and poor glycemic
control. From these the patient clearly has the first three risk factors but more can be assessed
using laboratory investigations.

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  Pneumonia: persons with diabetes have a greater frequency and severity of infection such as
pneumonia. The symptoms which presented one week before admission, which are non-productive
cough, intermittent fever accompanied by sweating, chills, palpitations, numbing global headache
and dull abdominal pain,loss of appetite and easy fatigability are in accordance with findings of
pneumonia.

 Madura Foot: is a chronic, specific, granulomatous, fungal disease. In mainly affects the foot. This
infection is endemic in Africa, India and Central and South America. Leg pain, burning sensation of
foot, fever, chills, leg swelling are in accordance with the finding of Madura foot but the Lack of
foot trauma, intermittent discharge of pus aren’t supportive but don’t rule out this diagnosis.

Diagnostic Workup
 Random Blood Sugar : to assess the sugar level in the blood
 CBC with differential, ESR : to assess for presence of infection
 Chest X-ray : for pneumonia
 Urine analysis : to assess for microalbuminuria
 Fasting lipid profile : for assessment of dyslipidemia
 Funduscopy : to assess the presence of retinopathy
 Doppler ultrasound : to assess the patency of the peripheral vessels
 Coronary angiography : to assess the patency of the coronary vessels
 ECG : to assess for presence of MI
 Hemoglobin A1c : for assessment of long term glycemic control

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