HOPI

• s- general (systemic) or localised (msk) fatigue,

• o- what the trigger of fatigue, whether in resting state or stress or acticity

• c- physical or mental fatigue

• r- include muscle weakness or breathlessness

• a- SOB, palpitation, chest pain, weight loss, headache, pallor, syncope, fever, poor sleep, weakness, night sweat, seizure, polyuria, postural dizziness due to postural hypotension, numbness

• t- fatigue occur at what time or all day

• e/r- exertion, stress, medication, fasting / rest, sleep, medication, after eating, posture

• s- how much the fatigue affect daily life

social history

• occupation, schedule

• diet and physical activity

• sleep pattern

• smoking, alcohol, drug abuse

• travel history

PMH

• chronic disease (HPT, DM, asthma, cvs related)

• previous anaemia or blood disorder

• surgery or hospital admission (medication, treatment)

• previous infection

• autoimmune

• similar episode

• use of medication (regular, sedative, OTC medication, traditional)

• BMI

FH

• red flags disease (chronic disease)

• history of anaemia

• cancer (MEN)

• autoimmune disease

• thalassemia

CVS related (IHD, heart failure)

metabolic disorder (DM, thyroid disorder, adrenal problem)

anaemia (IDA, GI bleeding)

autoimmune (Hashimoto thyroiditis, SLE, MS, fibromyalgia)

drug induce (ANTI-DEPRESSANT, ANTI-HISTAMINE, sedative anxiolytic hypnotic)

infection

respiratory related

psycological causes (stress)

CKD

Cancer

chronic fatigue syndrome

obstructive sleep apnea

loin pain - pain at back between rib and hip

vital sign ( BP,RR,HR

BMI

Blood glucose ( HbA1c, random plasma glucose)

FBC

urinalysis

renal function test

CVS related (IHD, heart failure) - less likely

metabolic disorder (DM, thyroid disorder, adrenal problem)

anaemia (IDA, GI bleeding)

autoimmune (Hashimoto thyroiditis, SLE, MS, fibromyalgia) - less likely

drug induce (ANTI-DEPRESSANT, ANTI-HISTAMINE, sedative anxiolytic hypnotic)

infection - less likely

respiratory related - less likely

psycological causes (stress)

CKD - less likely

Cancer - less likely

chronic fatigue syndrome

obstructive sleep apnea

Achilles tendon reflex - ankle reflex

temp- normal

HR - normal

RR - normal

BP - high

BMI - obese

pt. is alert and oriented

LF, suppurtive ulcer and w/ adjacent cellulitis extending to ankle joint, foot is warm, w/ palpable peripheral pulse

Achilles tendon reflex and vibration absent on the LF

systemic review - N/A

temp- normal borderline high

• no systemic infection, though inflammation to fight local infection

HR - normal borderline high

• inflammation to fight local infection

RR - normal borderline high

• inflammation, to fight local infection

BP - high

• HTN, due to metabolic syndrome, (i.e. DM, increase in blood glucose, endothelial dysfunction, small artery loss elasticity, increase in PVR)

BMI - obese

• risk factor of metabolic syndrome

pt. is alert and oriented

• no CNS involvement

L/F, suppurative ulcer and w/ adjacent cellulitis extending to ankle joint, foot is warm, w/ palpable peripheral pulse

• poor wound healing, pus formation, impaired neutrophil function, however still receive good perfusion

• pulses present at macrovascular, can rule out ischemic ulcer, thus, most likely neuropathic ulcer

• infection does spread to surrounding subcutaneous tissue, infection is progressive, require prompt management

Achilles tendon reflex and vibration absent on the L/F

• neuropathy problem

systemic review - N/A

Blood glucose ( HbA1c, random plasma glucose)

FBC

urinalysis

renal function test

swab ulcer for C&S

CVS related (IHD, heart failure) - less likely

metabolic disorder (DM, thyroid disorder, adrenal problem)

1. diabetes mellitus

2. thyroid disorder

3. addison's disease

anaemia (IDA, GI bleeding)

autoimmune (Hashimoto thyroiditis, SLE, MS, fibromyalgia) - less likely

1. Hashimoto's thyroiditis

2. SLE

3. MS

4. fibromyalgia

drug induce (ANTI-DEPRESSANT, ANTI-HISTAMINE, sedative anxiolytic hypnotic)

local infection

1. cellulitis - foot ulcer

respiratory related - less likely

psychological causes (stress)

CKD - less likely

Cancer - less likely

chronic fatigue syndrome

obstructive sleep apnea

hb low

wbc high

neutrophil, monocytes high

rbg high

glucose high in urine

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