LONG CASE

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Long case:



 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.          


   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 diagnosis and treatment plan

CHIEF COMPLAINTS:

65 Y Old female came  with C/O fever,Shortness of breath ,pedal edema 18 days back.

HISTORY OF PRESENT ILLNESS:


Patient was apparently asymptomatic 18 days ago then she developed fever with chills and rigors, SOB of grade 3 of insidious in  onset,gradually progressive.

Pedal edema present ,blisters over right foot was present which progressed to ulceration associated with swelling.
Ulceration on dorsal foot of right leg and in the calf area .
No h/o of cough and sore throat.
No C/O abdominal pain,loose stools,vomitings nausea.

Patient has history of applying hot fomentation to right leg following which she developed blisters over right foot  which eventually got Burst and formed an ulcer.
Following hospital admission there was history of urine retention for 24 hrs.

Grade 2 bed sores present B/L ON Gluteal region

Fasciotomy done on 8/11/23

EVENTS :

K/c/o-CAD
2015,20 -underwent stenting
2020-CABG

K/c/o-obstructive sleep apnea,sleep awakenings present ,COPD since 11 months

K/c/o-DM,HTN since15 years

November 8- SOB of grade lll associated with orthopnea

November 11- pedal edema

High grade fever

1 month back-hot fomentation—> blister (burst) —> ulcer and swelling of right lower limb

PAST HISTORY :


K/C/O Hypertension since 15 years on Tab Telma 40mg ,Tab MET XL trio

Diabetes since 15 years on Injection Mixtend SC 40U-X-40U,Tab Axagliptin 1000mg 

K/C/O  CAD -S/P CABG  in 2020 

K/C/O- COPD and obstructive sleep apnea SINCE 11 MONTHS ON BIPAP and nebulisation for sob 

Underwent hysterectomy in 1997 and oophorectomy i/v/o fibroid 


PERSONAL HISTORY:

Appetite-Normal 
Diet-Mixed
Bowels-Regular
Addictions -None 

FAMILY HISTORY:

Mother and father both are  are  diabetic and hypertensive

Father died of CAD

Her 3 sisters are diabetic and hypertensive underwent stenting.



GENERAL EXAMINATION:

Patient is C/C/C

Patient is obese.



Pallor present 



No signs of
 icterus,cyanosis,clubbing,lymphadenopathy
 
Pedal edema present from ankle to knee 


Vitals-

PR-85bpm
RR-18cpm
BP-150/80mm hg
GRBS-286 mg/dl

Systemic examination

CVS-S1,S2 heard no murmurs
P/A-soft,NT.
RS-wheeze present,orthopnea
CNS- joint position sense absent and no vibration sense noted 



ULCER 



FASCIOTOMY 








GRADE 2 BED SORE




CANDIDIAL INTERTRIGO 






Investigations 

15/11/23

RBS-296mg/dl

Serum magnesium-2mg/dl

TROPONIN-I-146pg/ml






17/11/23



25/11/23






26/11/23

27/11/23







28/11/23


LFT from 15/11/23 to 28/11/23


HEMOGRAM from 15/11/23 to 23/11/23


RFT FROM 15/11/23 TO 28/11/23


FEVER CHART 





Diagnosis:
Type 2 DM,K/C/O  CAD S/P CABG S/P in  2020,K/C/O HTN,AKI  ,candidial intertrigo +frictional dermatitis,S/P 8sessions of  hemodialysis done with obstructive sleep apnea 
Gangrene of right 5th toe,4th toe and ulcer over dorsum of foot and right calf,grade 2 bedsore of B/Lgluteal region ,S/P dysarticulation of right 5th toe,4th toe and debridement of ulcer and bed sore 


Treatment-
1.Oxygen inhalation to maintain saturation greater than 95%
2.Injection Meropenem 1gm IV/BD (12th hrly)-DAY 11
3.Injection linezolid 600mg IV/BD(12th hrly)-DAY 11
4.GRBS monitoring, Vitals monitoring 
5.TAB Atorvastatin 40mg RT/OD
6.inj pcm 1g IV/SOS
7.Inj pantop 40mg IV/OD BBF 
8.TAB Pcm 650mg RT/TID
9.TAB Acebrophylline 100mg rt/12 hrly
10.TAB Nodosis 500mg rt/12th hrly
12.TAB Shelcal CT Rt/od
12.TAB Orofer xt RT/od
13.Right lower limb elevation 
14.Inj Lasix 40mg IV/BD
15.I/O charting 
16.CLOTRIMAZOLE 1% cream LA BD 1 week
17.Absorb dusting powder LA/BD
18.Regular positioning change 2nd hrly
19.Alpha bed 
20.Inj metrogyl 500mg IV /TID (8th hrly)-DAY 10
21.Inj moxifloxacin 400mg IV/OD -DAY 7
22.Inj hydrocortisone 100mg IV/ prior to dialysis
23.Inj HAI s/c 8u-8u-6u
24.T.Amlong 5mg PO OD
25.Tab.ecosprin 75mg od
26.Tab clopidogerl 75mg 


UPDATES:



















                                                                        

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