He did not report painful urination or any discolouration of the  urine, feeling feverish or any loin pain. 

Past medical history 

There was no history of similar illness in the past. The patient had  never been hospitalised. 

Allergies and medications 

The patient had no allergies and was not on regular medications. 

Family history 

There is no family history of similar illness. 

Social history 

There was no history of smoking, alcohol consumption or drug  abuse.

Diff. diagnosis:

1. Infection (bacteria)

2. Diabetis

3. peripheral vascular disease (non-healing ulcer)

4. CVS disease - venous insufficiency

5. immunocompromised (HIV)

Further inv:

1. HOPI

   sites : exact location felt hurt sole or any other region

   onset:

   characteristic: color of pus , yellow: mild brown: chronic

   radiation: radiate to any other organ

   a/w sx : fever, headache , high BP - systemic review (sx of diabetes - polyuria, polydipsia (INCREASE IN THIRST) ,increased hunger, weight loss

   Time: changes during two months

   exarcerbating & relieving factor: what trigger/ relieve pain

   Severity : using scale 1 to 10

2. pmh : med condition, past surgeries , hospitalization & procedures

3. fam history : any fam members have similar sx (diabetes is can be hereditary factor)

4. social history : alcohol, smoke intake , drug abuse, dietary

   
   

Vital signs

The patient's values: Normal range

Temperature 37.2 ºC: 36.6 – 37.2ºC 

Heart rate 100 beats per minute :60 – 100 beats per minute 

regular sinus rhythm 

Respiratory  rate 16 breaths per minute: 12 – 16 breaths per minute 

 Blood  Pressure 150/100 mmHg: 120/80 mmHg 

BMI 33 kg/m² (normal range: 18.5 – 24.9 kg/m²)  

On physical examination,the patient was alert and oriented. 

Left foot: suppurative ulcer with adjacent cellulitis extending to the  ankle joint. The foot was warm with palpable peripheral pulses.  

Peripheral nerve examination: Achilles tendon reflex and vibration sensation were absent on the left foot. 

Review of other systems: unremarkable.

DIFFERENTIAL DIAGNOSIS

1. Infection (bacteria)

2. Diabetis mellitus

3. peripheral vascular disease (non-healing ulcer)

4. CVS disease - venous insufficiency

5. immunocompromised (HIV)

FURTHER INVESTIGATION

1. vital sign - temp, HR high,RR,BP high(check for orthostatic hypotension)

2. BMI - high BMI, high risk DM type 2 and venous insufficiency

3. PE- INSPECTION ( peripheral cyanosis, pallor, gangrene, scar, calluses). PALPATION (temp at leg, if cold indiacte low perfusion, check pulse if low indicate peripheral vascular disease). SENSATION (monofilament test to check nerve condition)

4. Neurological examination- CN examination, motor reflex, sensory, coordination balance, eye examination (tgk cataract, observe acetone on breath due high KB)

   
   

   
   

Cellulitis - bacteria skin infection that cause swelling, redness,warm at the affected area of skin

The patient's values: Normal range

Temperature 37.2 ºC: 36.6 – 37.2ºC 

Heart rate 100 beats per minute :60 – 100 beats per minute 

regular sinus rhythm 

Respiratory  rate 16 breaths per minute: 12 – 16 breaths per minute 

 Blood  Pressure 150/100 mmHg: 120/80 mmHg

BMI - 33kg/m2

patient was alert and oriented

suppurative ulcer with adjacent cellulitis extending to the  ankle joint

foot was warm with palpable peripheral pulses

Achilles tendon reflex and vibration sensation were absent on the left foot

Other systems unremarkable

LFT: within a reference range. 

RFT: within a reference range. 

Foot ulcer swab culture and sensitivity: Bacteroides fragilis sensitive to metronidazole, carbapenems, chloramphenicol, and  combinations of a penicillin and beta-lactamase inhibitors. 

The patient was diagnosed to have type 2 Diabetes mellitus  complicated with a foot ulcer and started on metformin treatment. The  patient showed improvement, blood sugar levels decreased. His foot  was treated with a daily dressing in addition to an oral antibiotic  prescription.  

The patient was counselled to optimise his weight and stick to a healthy  lifestyle, including adjustment of the diet. A goal was set on how much  weight he should lose by the next follow- up. 

The patient's values: Normal range

Temperature 37.2 ºC - slightly high , compensatorymechanism dt infection

Heart rate 100 beats per minute - psychological n inflammatory respons / obese , atherosclerosis

Respiratory  rate 16 breaths per minute - pyschological response

Blood  Pressure 150/100 mmHg ; obese , atherosclerosis, arteriolosclerosis (complications)

BMI - 33kg/m2 ; obesity - lead to type 2 DM, insulin resistance - impaired glucose uptake, have sx of polyuria

patient was alert and oriented - not in respiratory distress condition

suppurative ulcer with adjacent cellulitis extending to the  ankle joint - pus formation due to infection, DM type 1 & 2

foot was warm with palpable peripheral pulses - rule out PVD // cardinal signs of inflammation

Achilles tendon reflex and vibration sensation were absent on the left foot - NO diabetic neuropathy - NO nerve damage

Other systems unremarkable

DIFFERENTIAL DIAGNOSIS

1. Diabetis mellitus

2. Infection (bacteria)

3. peripheral vascular disease (non-healing ulcer)

4. CVS disease - venous insufficiency

5. immunocompromised (HIV)

FURTHER INVESTIGATION

• FBC - blood test

• Serum electrolytes - Hydration status

• Random BG test

• Blood C&S - sample from blood / pus

• Urinalysis - detect presence of glucose

• HbA1c - detect risk of complication

• Ultrasound - to confirm venous insufficiency

• Magnetic resonance - Vein image ; any obstruction

• Fasting BG test - DM >7

• OGTT - Fasting blood sample | DM >11.1

• LFT

2. Describe the regulation of insulin release, action and insulin signalling  pathways.  

3. Correlate the defect in the action of insulin with clinical manifestation of  diabetes mellitus (DM). 

4. Describe the classification of DM, explain the causes and mechanism of type 2  DM. 

5. Outline the relationships between the clinical manifestations of type 2 DM and  their underlying mechanisms. 

6. Describe complications of DM. 

7. Describe the relationship between type 2 DM and foot ulcer. 8. Describe the scientific rationale for the laboratory tests in diagnosing DM and  its monitoring and the interpretation of the results of the tests. 

9. Outline the principles of management of DM. 

10. Describe the pharmacological basis of medications used in the treatment of  DM.

-Hb:low: type 2 cause anemia (easy fatigue), cause chronic kidney disease decrease EPO, poor nutrition,

-TWBC: high active infection (purulent)

-neutrophil: high -bacteria -pus (MAIN)

-monocyte: high- infection

-OTHER MARKERS: EG: compliment protein (for chronic infection indication)

-random glucose: high- -ve chronic diabetes (>15)

-normal electrolyte of kidney fx

-urinalysis: has glucose - cannot reabsorb into blood (DM)

-NO nitrate: no UTI

-no LEUKOCYTE: no inflammation

-Hba1c: specific for DMT2

-Foot ulcer swab culture and sensitivity: Bacteroides fragilis: gram -ve, anaerobic, normal in colon, normal microbiota

-sensitive to metronidazole, carbapenems, chloramphenicol, and  combinations of a penicillin and beta-lactamase inhibitors: diff. mechanism so broad spectrum, this bacteria is sensitive to all of these antibiotics (use blood C&S) to prevent bacterial resistance

-The patient was diagnosed to have type 2 Diabetes mellitus  complicated with a foot ulcer and started on metformin treatment: DMT2 d/t insulin resistance > not bind to receptors > glucose cannot pass to the cell membrane > glucose remain in blood

-metformin: anti hyperglycemic drug > control blood glucose

-The  patient showed improvement, blood sugar levels decreased: pt follow treatment regiment

- His foot  was treated with a daily dressing in addition to an oral antibiotic  prescription: prevent infection, prevent complication like osteomyelitis, promote wound healing

-The patient was counselled to optimise his weight and stick to a healthy  lifestyle, including adjustment of the diet: obese > DM, dyslipidemia, heart disease > to prevent those complications

NASIB SAPE YG DAPAT