GM Case 1

3rd  march 2023

Case scenario...... 

Hi, this is m sindhuja 3rd Bds. This is an online eblog book. Discuss our patients health data after taking his consent. This also reflects my patient centered online learning portfolio. 

Case Sheet:45 yrs old male c/o ulcer over left foot since 1 year. 

COMPLAINTS AND DURATION:

                              Ulcer over left foot since 1 year. 

History of present Illness (HOPI) :

            Patient was apparently asymptomatic until 1 year back. Later he met a accident and injured to left leg. After injury wound developed over left leg. There is a Associated fever. 

                                                          History of past illness:    

                                                                No h/o burning micturation /pain Abdomen/chest pain/palpitation.

No decreased urine output /pedal edema. 

K/c/o poliomylelitis since childhood 

Not a k/c/o DM, HTH/TB/Asthma/epilepsy/CVA/CAD/thyroid disease. 

Personal History:

      Normal appatite, mixed diet with regular bowl and bladder habits and addiction to alcohol occasionally and micturation normal, no known allergies. 

Family History :

     Not significant.

General Examination: 

   Patient is conscious 

No pallor ,

No cynosis ,

No icterus ,

No clubbing, 

No malnutrition, 

No edema.,

No lymphadenopathy. 

VITALS

Pulse Rate= 86 Bpm

BP= 110/80

Spo2= 98%

Respiratory Rate=16cpm

PROVISIONAL DIAGNOSIS: 

          Traumatic nonhealing ulcer. 

Q/A:

       How many days will it take to get cure?