GM CASE DURGA T 131


This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission.

I have been given this case to solve in an attempt to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including, history, clinical findings, investigations, and come up with a diagnosis and treatment plan.

CASE:

This is a case of 46yr old male who is shopkeeper by occupation presented with chief complaint of swelling of left lower limb since 15days 

HISTORY OF PRESENT ILLNESS:

Patient was apparent asymptomatic15days back then he had consulted a physician outside for the B/L pedal edema and 5 days back in an intoxicated state patient fell down from the bike, when he suffered an injury to his left leg and had swelling of that limb for which he received treatment from outside hospital for 3days but as the wound was not healing, he was referred to our hospital.

   

There was h/o fever 3days back which was low grade and continuous fever and was not associated with chills and rigors and was relieved on medication. 


He also had h/o constipation for 3days followed by passage of loose stools 2 -3 episodes non foul smelling and no blood tinge.


HISTORY OF PAST ILLNES:

NO h/o constipation, loose stools 

h/o seizurese 15 years back since then he is on medication.

TREATMENT HISTORY :

 k/ c/o diabetes since 5 months and he is on medication 

not k/c/o  hypettention, CAD,asthama, tuberculosis 

SURGERIES: 

h/o head injury 15yrs back when patient was diagnosed with intracranial bleed and was taken for surgery.

PERSONAL HISTORY:

Diet: veg

Appetite: normal

Bowel and bladder: Regular 

Micturition: normal

Allergies: no
habits/addicitions:
a) alcohol: regular since 15 years 
b) tobacco: snuff since 15 years 3 packs per day
Family history:

not neccesary

GENARAL EXAMINATION


VITALS:

Pulse rate: 94 bpm
Respiratory rate: 18/min
BP: 160/100 mmHg
Temperature: afebrile
SPO2: 99% at room air
            
Pallor: absent
Icterus: absent
Clubbing: absent
Cyanosis: absent
Lymphadenopathy :absent
Edema of feet: present, 
Malnutrition :absent
Dehydration :absent

SYSTEMIC EXAMINATION 

CVS
  • S1 and S2 heard
  • No thrills
  • No murmurs
Respiratory System
  • Vesicular breath sounds heard
  • Trachea is in central position
  • No wheezing
  • No Dyspnoea
Abdomen
  • obese shaped abdomen
  • No tenderness
  • No palpable mass, no organomegaly
  • Bowel sounds are heard
CNS
  • Conscious and normal speech
  • Normal gait
  • Cranial nerves normal
  • sensory system normal
  • Motor system normal
  • No signs of meningeal irritation.

INVISTIGATIONS:


























 



























PROVISIONAL DIAGNOSIS : 


Left lower limb cellulitis with sepsis with k/c/o DM type 2 since 5 months with COPD with OSA with hypokalemia with mild ARDS







TREATMENT: 
• On 30/6/2021 
   - proped up posture 
   - O2 inhalation @ 4-6 47/min
   - Inj. meropenam 1g/iv/BD 
   - inj. clindamycin 600 mg /iv 
   - Inj. pan 40 mg /od
   - inj. zofer 4 mg /iv/tid 
   - inj HAI s/c acc to GRBS 
   - neb. duolin 5th hrly and budeeort 12th hrly 
   - inj levipil 500mg / Iv/BD
   - inj CLEXANE 40mg /sc /od 
   - IVF 1 NS, 1 RL@75ml per hr
   - 2egg white /day 
   - piotein powder in 1 glass of milk/po/bd (D1ABEAC PROTIEN POWDER )
   - Syp. POTCHLOR 10ML 1GLASS OF WATER /PO/BD 





30/7/2021 

- proped up posture 
   - O2 inhalation @ 4-6 47/min
   - Inj. meropenam 1g/iv/BD 
   - inj. clindamycin 600 mg /iv 
   - Inj. pan 40 mg /od
   - inj. zofer 4 mg /iv/tid 
   - inj HAI s/c acc to GRBS 
   - neb. duolin 5th hrly and budeeort 12th hrly 
   - inj levipil 500mg / Iv/BD
   - inj CLEXANE 40mg /sc /od 
   - IVF 1 NS, 1 RL@75ml per hr
   - 2egg white /day 
   - piotein powder in 1 glass of milk/po/bd (D1ABEAC PROTIEN POWDER )



DAY 31/7/2021
proped up posture 
   - O2 inhalation @ 4-6 47/min
   - Inj. meropenam 1g/iv/BD 
   - inj. clindamycin 600 mg /iv 
   - Inj. pan 40 mg /od
   - inj. zofer 4 mg /iv/tid 
   - inj HAI s/c acc to GRBS 
   - neb. duolin 5th hrly and budeeort 12th hrly 
   - inj levipil 500mg / Iv/BD
   - inj CLEXANE 40mg /sc /od 
   - IVF 1 NS, 1 RL@75ml per hr
   - 2egg white /day 
   - piotein powder in 1 glass of milk/po/bd (D1ABEAC PROTIEN POWDER ) 

Patient was referred to psychiatrist i/v/o  h/o chronic smoking and chronic alcoholism, for which psychiatrist has added 
     - TAB. PREGABALINE 
     - TAB. BENXL
     - NICOTINEX CHEWING GUMS 



On 1/8/2021
proped up posture 
   - O2 inhalation @ 4-6 47/min
   - Inj. meropenam 1g/iv/BD 
   - inj. clindamycin 600 mg /iv 
   - Inj. pan 40 mg /od
   - inj. zofer 4 mg /iv/tid 
   - inj HAI s/c acc to GRBS 
   - neb. duolin 5th hrly and budeeort 12th hrly 
   - inj levipil 500mg / Iv/BD
   - inj CLEXANE 40mg /sc /od 
   - IVF 1 NS, 1 RL@75ml per hr
   - 2egg white /day 
   - piotein powder in 1 glass of milk/po/bd (D1ABEAC PROTIEN POWDER )
     - TAB. PREGABALINE 
     - TAB. BENXL
     - NICOTINEX CHEWING GUMS 

On 2/8/2021
DIABETES DIET  

INJ MEROPENEM 

INJ CLINDAMYCIN 600MG / IV/TID 

INJ PAN 40 MG /1V/TID 

INJ 20 FER 4MG /4MG /1V /BD  

INJ HAI S/C ACC TO GRBS 


INJ LEVIPIL 900 MG /1V/BD 

INJ CLEXANE 40 MG /SC /OD  

  - TAB. PREGABALINE 
     - TAB. BENXL
     - NICOTINEX CHEWING GUMS

On 3/8/21

PLENTY OF ORAL FLUIDS 3L/DAY
IVF 75ML/HR
PROPPED UP POSITION
INTERMITTENT LPAP 4TH HRLY
INJ PAN 40 MG /1V/TID
INJ HAI S/C ACC TO GRBS 

NEB© IPRVENT and 8TH HRLY
BUDECORT

STRICT IO CHARTING

TAB LEVIPIL 500 MG /PO/BD 

INJ CLEXANE 40 MG /SC /OD  

TAB SAPROLAC  DS/PO/BD
ORS SACHET IN 1LT OF WATER
SYP. POTCHlOR  15 ML IN 1GLASS OF WATER/PO/BD
T. DOLO 650 MG /PO/SOS
T. AMLONG 10MG /PO/OD
3 EGG WHITES /DAY
PROTIEN POWDER 2 TB. SPOON IN MILK /PO/TD
T. PREGABA. M/PO/H/s
T. BENXL/PO/OD
NICOTEX GUMS 4MG /PO/OD
BP/PK/SP O2 MONITORING

ON 4/8/21

PLENTY OF ORAL FLUIDS
IVF 75ML/HR
PROPPED UP POSITION
INTERMITTENT LPAP 4TH HRLY
INJ PAN 40 MG /1V/TID
INJ HAI S/C ACC TO GRBS 

BUDECORT

STRICT IO CHARTING

TAB LEVIPIL 500 MG /PO/BD 

INJ CLEXANE 40 MG /SC /OD  

TAB SAPROLAC  DS/PO/BD
ORS SACHET IN 1LT OF WATER
SYP. POTCHlOR  15 ML IN 1GLASS OF WATER/PO/BD
T. DOLO 650 MG /PO/SOS
T. AMLONG 10MG /PO/OD
3 EGG WHITES /DAY
PROTIEN POWDER 2 TB. SPOON IN MILK /PO/TD
T. PREGABA. M/PO/H/s
T. BENXL/PO/OD
NICOTEX GUMS 4MG /PO/OD
BP/PK/SP O2 MONITORING











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