60yr old female with c/o swelling of the left lower limb since 5days

 

60yr old female with c/o swelling of the left lower limb since 5days

ROHITH SOMANI

Roll no.147

This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed 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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .


 

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 diagnosis and treatment plan.

CASE DISCUSSION:

Patient came to casualty with c/o swelling of left lower limb since 5days .

History of present illness

 patient was asymptomatic 8days back she had trauma to her left foot.After which she developed low grade fever for 1-2 days,which got subsided on its own.then she developed swelling of left lower limb since 5days and blister over inner aspect of left thigh and ankle region
H/o application of hot fermentation with rock salt after which developed burns over left
thigh after which she developed burns
No h/o nausea, vomiting,loose stools,cough,burning micturition,
No h/o sob, palpitations,orthopnoea,PND

Past history 

K/c/o DM2 since 10yrs on metformin 500mg 
n/k/c/o HTN,asthma,CAD,CVD,Epilepsy,thyroid disorder

Personal history

Appetite-normal
Diet-mixed
Bowel and bladder - not passed stools since 2days
Sleep-adequate
No history of allergy to food or drugs

GENERAL EXAMINATION

Patient is in drowsy state. Moderately built moderately nourished
No pallor,icterus ,cyanosis, clubbing, generalised lymphadenopathy, edema of left limb present.
Vitals: 
temperature:99.1°F
Pulse rate:92bpm
Resp rate:18cpm
BP:100/50mmhg
Spo2:98%

SYSTEMIC EXAMINATION

cvs

S1S2 heard
No cardiac murmurs
Apex beat heard at 5th ICS

Respiratory system

Normal vesicular breath sounds heard
Position of trachea - central

Abdomen

Inspection: shape-slightly distended
Umbilicus - central and inverted
All abdominal quadrants moving equally on inspiration and expiration.

Palpation:  soft,non tender
Liver and spleen not palpable

Percussion: resonant note heard all over abdomen on percussion

Auscultation: bowel sounds are heard on auscultation

CNS


Pt is in drowsy state,coherent and non cooperative 
Speech- inappropriate sounds
No signs of meningeal irritation. 
Cranial nerves- intact
Sensory system- normal 
Motor system:
Tone- normal
Power- bilaterally 3/5
Reflexes: Right. Left. 
Biceps. ++. ++
Triceps. ++. ++
Supinator ++. ++
Knee. ++. ++
Ankle ++. ++

                   Wound site



                      Blister over left foot



                     Blister over left thigh





                     Ulcer after debridement

Investigation

Serology-negative

HEMOGRAM
Hb-8.3%
TLC-15,000
PCV-24.3
MCV-87.4
MCH-29.9
RBC-2.78
PLT-1.4

RFT
CREATINE -3.2
S.UREA-154
Na+127
Cl-98
K+4.4

LFT
TB-1.79
DB-0.20
AST-16
ALT-10
ALP-94
Alb-2.5
A/G-0.73

APTT-37sec
PT/INR-19sec/1.40

Serum osmolality-289.8mosml/kg

ABG
pH-7.267
pCO2-15.5
pO2-83.3
HCO3-10.1

Diagnosis

Altered sensorium 2° to uremic encephalopathy pre renal AKI with left limb cellulitis k\c/o DM2 since 15 yrs



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