77Y OLD MALE WITH LEFT LOWER LIMB SWELLING

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 Dr.N.Deepa , Internee

Roll no. 105

I've 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. 

Date of admission : 31/05/2023


CASE : 

Patient was brought to the opd with complaints of fever since 4 days and blisters over the left lower limb since 1 day.

HISTORY OF PRESENT ILLNESS:

Patient was apparently normal 8 days back,later he felt pain in his left leg for which he applied zandu balm over the left limb.3 days later he developed edema of left lower limb which gradually progressed from the foot to above knee, followed which he developed blisters .
H/o fever 4 days back which is continuous,low grade ,not associated with chills and rigors.
a/w burning micturition
No h/o cough,cold,loose stools, vomitings,sob.
Urine output decreased on the day of admission.
C/o difficulty in swallowing since 3 days

PAST HISTORY :

H/o similar complaints 2 years back .He had a thorn prick in the left calf region followed which he developed pain and redness and was treated accordingly.

Not a k/c/o DM-2,HTN,TB,CAD,CVA
No previous surgical history
No history of blood transfusions

PERSONAL HISTORY:

Normal appetite
Mixed diet
Sleep Adequate
Bowel movements - regular, episode of malaena +,now resolved
Bladder movements- regular, burning micturition+
Addictions - alcoholic for 50  yrs -90ml every day
Smoker(chutta) 2-3 per day for 50 yrs

FAMILY HISTORY :

No history of diabetes or hypertension in the family.

GENERAL EXAMINATION :

Patient is examined in a well lit room after taking the consent. 
He is conscious, coherent and cooperative. 
Well oriented to time, place and person. 


Pallor - present                  

Icterus - absent 

Cyanosis - absent

Clubbing - absent

Generalized Lymphadenopathy - absent

Bilateral pedal edema - edema of left lower limb extending till mid thigh


VITALS :

Pulse - 80 beats per minute, regular in rhythm, normal in volume and character of vessel, no radio- radial delay, no radio - femoral delay. 

Respiratory rate - 18 cycles per minute

Blood pressure - 100/70 mm of hg, measured in the left arm in supine position

Temperature - 98.6F

Spo2 - 98% at room air









Temperature charting:





SYSTEMIC EXAMINATION : 

CVS : 
    
S1 S2 heard, no murmurs

CNS : 

No neurological deficit

RS :

Bilateral air entry present,no adventitious sounds.

ABDOMINAL EXAMINATION : 

Soft,non tender,bowel sounds+


LOCAL EXAMINATION:

Skin over the  left leg is tense with blebs
Blackish discoloration over posterior aspect of left thigh
Tenderness present upto midthigh




INVESTIGATIONS:





DIAGNOSIS:

Left lower limb cellulitis AKI(renal)on CKD stage 5  with thrombocytopenia 

TREATMENT:

1.IV FLUIDS NS @ 75 ml/hr  
2.Inj.MONOCEF 1 gm IV BD
3.INJ. METROGYL 500mg IV BD
4.Inj.LASIX 20mg IV BD
5.Tab.MET- XL 12.5mg PO/OD
6.Tab.DOLO 650mg PO TID
7.TAB.ATORVASTATIN PO OD
8.ZYTEE GEL for local application 15mins before food
9.Monitor vitals


















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