I am Saranya ,currently an intern posted in the department of General Medicine
Greetings to all my readers;
This is an elog documenting the patients that I witness during my Rotatory Internship Postings to enforce a greater patient centered learning
DEIDENTIFICATION :
The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.
CONSENT :
An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references.
ACKNOWLEDGMENT
I convey my regards to Dr. Lohith and Dr.Narsimha Reddy ( Resident , Department of General Medicine ) for guiding me regarding the case .
INTRODUCTION :
My patient is a 70 year old man, a labourer in young days,now retired, resident of a rural district of South India
CHIEF COMPLAINTS :
Our patient came with complaints of wound on Right foot since 2 years , fever since 1 day.
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 2 years back when he gives history of trauma to right foot resulting in trauma ( thorn pricking on the sole of the right foot ) , that wound was not healing, since then there is ulcer on his right sole.
Patient has pain in his right foot, A/w pins and needles; tingling and numbness in both upper and lower limb.
Patient is having fever since 1 day.
High grade fever, intermittent , resolving with antipyretic medication
OTHER CO MORBIDITIES :
He is a k/c/o DM 2 , HTN since 2 years on oral medications.
No c/o SOB, Chest pain ,Palpitation orthopnea , PND , pedal edema
C/o frequency , urgency , dribbling of urine
Biopsychosocial history :
Patient is too old to go to work, previously he used to be a labourer but has stopped going to work, his wife has passed away, children have left the house ,settled in other parts of the city and they do not maintain contact with their father, he lives all alone in his rural house, no care taker, money and daily basic household needs are also a constraint for him. He came to the hospital by himself because he was troubled by his wound and fever had also added up.
His Daily Routine :
His day begins early in the morning when he needs to wake up even when he does not feel like, because he knows that he has to get going ,to fill vessels of water for the day, for drinking and household chores ,and after a certain time , the source water stops, hence that is the way the day begins ,
Even though the foot is painful, and he is weak with the burden of age and life events ,he has no other option but to pull himself up and head towards making some food for himself , he has somehow managed to buy a small cooking gas cylinder in which he cooks his 2 square meals of the day, which mostly comprises of rice and a curry
We wouldn't mind to eat a better variety and maybe a more healthier plate but his resources and energy to make the meals by himself is too constrained to even think of those options
This he does just for survival ,and because when in hunger he needs to eat atleast something , he also mentions a sentence saying( in his own language ; that I shall translate in English for the readers understanding
" My hunger has died , no don't think I don't feel hungry, I do ,but when I think ,again It is me who has to arrange everything , a part of the hunger vanishes ,and rest of it vanishes when I think that everyone in my life left me alone and left ".
After his meal preparation, he eats his food , takes some rest , and then again gets started in washing the used utensils , and once in couple of days cleaning the room.
Through the day, In between the works he tries to rest at times ,
In the late afternoons , some days he goes out to buy small necessary things ,going and coming back,takes a lot of time,since he walks slowly with the assistance of a stick.
He finishes his dinner,
And goes to bed.
Clinical Examination :(pictographical ) :
Vitals :
BP: 140/ 80 hg
Pulse : 80 bpm
Rr : 14 cpm
Temperature: Febrile
History of self amputation of 3rd toe ( metatarsal and phalanx) ,toe had become shriveled and shrunken after which he went to a physician at a local region, who suggested the toe had to be taken off since it had " died "
Correlating with imageology
