A75 yr old man presented with Painful lesions and swelling over left leg

A 75yr old patient , resident of Narketpally,  farmer by profession , presented to the casualty with complaints of painful lesions and swelling over left leg. 


Date of Admission: 31/05/23


CHIEF COMPLAINTS 

Painful lesions and swelling over left leg since 4 days . 


HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 4 days back . Then he applied zandu balm over left limb and developed swelling which was gradually progressive. 

He had h/o fever since 4 days , not associated with chills and rigor 

He had a h/o similar complaints 1 yr back followed by trauma . 


HISTORY OF PAST ILLNESS 

Not a K/c/o diabetes, hypertension, asthma , epilepsy tuberculosis , CAD

No surgical history

No history of Blood transfusions


PERSONAL HISTORY


Occupation: Farmer. 

Patient is married .

Patient takes mixed diet and has a normal appetite.

Sleep : Regular 

Bowel and bladder movements are normal.

No known allergies .

 Addictions - Alcohol : 90ml at night .

                 Bedi  : 3 times daily.


FAMILY HISTORY 


Not significant . 


GENERAL EXAMINATION 


Pallor :Not seen



Icterus : Not seen

Cyanosis : Not seen


Clubbing : Not seen


Lymphadenopathy : Not seen


Edema : Seen - pitting type .





VITALS


Temperature : 98.3℉


PR : 90 beats per minute


BP : 100/70 mm of Hg


RR : 20 cycles per minute


SpO2 : 96% in room air


Blood Sugar (random) : 97mg/dl


SYSTEMIC EXAMINATION


CARDIOVASCULAR SYSTEM EXAMINATION


s1 and s2 heard

Thrills absent

No cardiac murmurs


RESPIRATORY SYSTEM

Normal vesicular breath sounds heard.

Bilateral air entry present

Trachea is in midline.


ABDOMINAL EXAMINATION


INSPECTION


Shape - Scaphoid


Equal movements in all quadrants 


No visible pulsation, dilated veins and localized swellings.


PALPATION


Liver , spleen not palpable.


No tenderness 


CENTRAL NERVOUS SYSTEM EXAMINATION


Conscious and coherent 


Speech : Normal 


No signs of meningeal irritation 


Neck stiffness: no 

Kernig's sign : no 

LOWER LIMB EXAMINATION


INSPECTION 


 Skin over the lower limb is tense with blebs . 


Blackish discoloration over the posterior aspect of left thigh 


 Single erythematous patch over the lateral aspect of left thigh


  Bullae noted over the dorsum of left foot and leg . 


PALPATION


Tenderness present upto left thigh

Local rise of temperature present  

Fluctuation is present .

 Skin is tense . 

Pitting type of edema present over Rt. lower limb till knee joint.


PROVISIONAL DIAGNOSIS : AKI on CKD stage V with lt. lower limb cellulitis with sinus arrythmia and thrombocytopenia.

INVESTIGATIONS


1) BACTERIAL CULTURE AND SENSITIVITY REPORT 

Dt : 08/06/23


Dt : 06/06/23 


Dt : 03/06/23 



2) USG 

Dt : 06/06/2023 


3) ECG 

Dt : 31/05/23

Dt: 06/06/23 




4) 2D ECHO 

Dt : 01/06/23 


5) GRBS 

Dt - 31/05/23 


6) BLOOD UREA

Dt : 31/05/23


7) SERUM CREATININE

Dt : 31/05/23


8) SERUM POTASSIUM

Dt : 31/05/23



9) SERUM SODIUM

Dt : 31/05/23


 10) LFT 

Dt : 31/05/23


11) SERUM PHOSPHORUS

Dt: 31/05/23


12) SERUM CALCIUM 

Dt: 31/05/23


13) SERUM CHLORIDE 

Dt : 31/05/23


14) INTAKE AND OUTPUT CHARTS 

Dt : 02/06/23

Dt: 03/06/23

Dt : 04/06/23

Dt : 05/06/23

Dt : 06/06/23

Dt : 07/06/23


Dt : 08/06/23

15) FEVER CHART 


TREATMENT


1. Normal diet 


2. Inj. Monocef 1gm IV BD


3. Inj. Metrogyl 400mg IV TID


4. Inj. Pantop 40mg IV OD


5. Tab. Dolo 650 mg PO BD


6. Tab . Mut PO OD 


7. Tab . Limcee PO OD


8. Foot end elevation . 










Comments

Post a Comment

Popular posts from this blog

A 48 yr old man presented with weakness in lower limbs and burning sensation of feet

Image
Hi, I am princy rose , 5 th sem medical student.This is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio. June 7,2023 Case scenario...... CASE SHEET: A 48 year old male farmer by occupation,resident of chintapalli came to the opd with chief complaints of  WEAKNESS OF BOTH LOWER LIMBS SINCE 6MONTHS BURNING SENSATION OF FEET SINCE 1 MONTH HOPI:: Pateint was asymptomatic 6 months back then he developed weakness of both lower limbs which is insidious in onset and gradually progressive. Associated with burning sensation of feet and pain in the calf muscle Patient also complaint of losing footwear while walking Patient also complaints of tingling sensation in both feet but can't appreciate it became burning sensation is more Patient was able to walk on his own till I month back but since 1 month patient needs supply to walk Visited local hospital 6 months back and using treatment since then P
Read more

A 65 year old woman presented with shortness of breath and pedal edema.

Image
August 16 , 2022 Hi ,  Iam Princy rose ,3rd semester student. This is an online elog book to discuss our patients health data after taking his consent. This also reflects my patient centered online learning portfolios. A 65 year old woman farmer by occupation came to causality with complaints of shortness of breath and pedal edema. CHEIF COMPLAINTS : > SOB for last 4 days  > Cough for last 4 days > Pedal edema for last 4 days > Pain in lower limb for last 4 days  HISTORY OF PRESENTING ILLNESS :  Patient was apparently asymptomatic 4 months back. In April , She had SOB on exertion with tingling sensation in both upper and lower limbs, pedal edema and decrease in urine output ( creatinine : 3.1mg/dl ) for which she got treated in local hospital and her symptoms got relieved.   She had nausea , vomiting ,weakness ,burning micturition and pain in lower limb (creatinine : 3.8mg/dl uric acid:5.6mg/dl) again by end of June for which she was treated and all her complains got re
Read more

A 67 year old man presented with SOB and Fever

Image
 Hi, I am princy rose , 5 th sem medical student.This is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio. June 5,2023 Case scenario....... CASE SHEET: A 67 year old male barber by occupation,resident of miryalaguda came to the opd with chief complaints of  Shortness of breath since 1 week  Fever since 4-5 days HOPI : Pateint was asymptomatic 1 week back then he developed shortness of breath grade 2-4 aggrevating on doing work, walking and temporarily relived on medication and fever for which he went to local hospital and they gave medication but symptoms are not relieved and then they went to miryalaguda hospital for checkup and they referred to our hospital. He also had fever since 4days high grade evening raise temperature associated with chills and rigors relieved by medication and increases again. H/O decreased urine output since 6 months C/o pain abdomen on &off left lumbar regio
Read more