GM E-Log J. Mounika. Roll(51)

 

Hi all. This is Mounika, a third semester medical student. 
            This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 


Note :This is an ongoing case and will be updated as and when the information is provided. This e-log has been made under the guidance of Dr. Siddharth. 

A 70 YEAR OLD MALE WITH SOB AND SWELLING, DISCHARGE FROM RT. LOWER LIMB( CELLULITIS) 

Chief complaint :

• Altered sensorium , since 2 days

• SOB grade IV , since 5 days

• Pedal edema grade III, since 7 days

• Rt. Lower limb cellulitis, since 7 days


History of presenting illness:

• A 70 yr old male, farmer by occupation, was apparently asymptomatic 2 yrs back. 

• Had h/o CVA 2 yrs back and for which he used medications for 4 months, and stopped. 

• k/c/o HTN since 2 yrs and is on regular medication

• k/c/o CKD since 2 yrs and is on conservative management

•1 1/2  yr back, had h/o trauma - Lt. femur

• 1 yr back - Lt. arm # , for which casting was done

• 15 days back, he had h/o trauma to Rt. Lower limb which gradually progressed to rt. Lower limb cellulitis

• c/o pedal edema grade - III, pitting type, relieved on medication

• c/o SOB grade II-III, progressed to grade IV

• H/O chest pain and chest tightness

• No c/o palpitations, syncopal attacks

• decreased urine output + , facial puffiness +

• No c/o orthopnoea, PND, burning micturition

History of past illness:

• No h/o DM, CAD, TB, epilepsy, asthma


Treatment history:

•Has a treatment history of HTN since past 2 yrs

• Has no treatment history of DM, CAD, asthma, TB, antibiotics, hormones, chemoradiation


Personal history:

• Farmer by occupation

• Has lost / decreased appetite

• Follows a mixed diet

• Has regular bowel habits

• Has decreased frequency of micturition

• Has no h/o allergies

Family history:

• Has no family history of DM, HTN, heart disease, stroke, cancers, TB, asthma. 

Physical Examination:

• Pallor - yes
• Cyanosis - no
• Lymphadenopathy - no
• Clubbing of toes/fingers - no
• Oedema of feet - yes

Vitals :

• Temperature : 95.7 °F
• Pulse rate : 92 / min
• Respiratory rate : 24times /min
• BP : 11/70 mmHg
• SPO2 - 98%
• GRBS : 104 mg

Systemic Examination:

A. Cardiovascular system

• No thrills and no cardiac murmurs 
• S1, S2 heard

B. Respiratory system

• Dyspnoea present
• No wheeze 
• Trachea position - central
• Breath sounds - vesicular
• BAE +

C. Abdomen

• Shape of abdomen - scaphoid
• No tenderness, no palpable mass
• Normal hernial orifices
• No free fluid, no bruits present
• Liver, spleen are not palpable
• Normal bowel sounds present
• soft and now tender

D. Central nervous system

• Level of consciousness- drowsy 1 arousable
• Speech - normal
• No neck stiffness and no kerning's sign
• Glasgow scale - 15/15

PROVISIONAL DIAGNOSIS:

       ?    AKI ON CKD
        ?   UREMIC ENCEPHALOPATHY
        ? RT. LOWER LIMB CELLULITIS



Investigations:

ON 19.7.21













ON 20.7.21






ON 21.7.21





Treatment :

1. INJ. LASIX  40mg IV/BD
2. NEB T DUOLIN 8th hourly
                Budecort 12th hourly
3. TAB. NODOSIS 550mg PO/BD
4. TAB SHELLCAL 500 mg PO/OD
5. TAB. CLINDIPINE 10mg PO/OD
6. INJ. PIPTAZ 2.25gm/IV /QID /8th hourly
7.T. ECOSPRIN 75mg/PO/HS
8. T. ATORVAS 20mg/PO/HS
9. BP/PR/RR/SPO2 charting 4th hourly
10. GRBS charting 6th hourly
11. STRICTLY I/O CHARTING

On cross consultation with surgery dept. 

On inspection: ( of rt. leg) 

• Reddish, wrinkling of skin is present
• ulcer size  3×4×7 cms
               Margin sloping
               Surrounding skin erythematous
               No line of demarcation seen
• present over the rt. Shin of tibia, discharging pus
• oedema extending from toes to skin above knees
• no necrolic pouches present on toe nails






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