70 yr old male with foot ulcer

August 05, 2023

70 Year old man with foot ulcer

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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

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 "

HISTORY OF PAST ILLNESS:

k/c/o DM 2 , HTN since 2 years on oral medication

FAMILY HISTORY:

Insignificant

PERSONAL HISTORY:

Diet:mixed

Sleep: adequate

Bowel and bladder movement: regular

No allergies

No addictions

Vitals:

Bp:140/80mmhg