General medicine case 1:-

Aug 10,2021

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Date of admission: July 29,2021

This is a case of 46 year male patient  who is a shopkeeper by occupation presented with chief compliant of swelling of left lower limb since 15 days.        

HISTORY OF PRESENT ILLNESSES:-

Patient was asymptomatic 15 days back then he consulted a physician outside for B/L pedal edema and 5 days back in an intoxicated state patient fell down from the bike, where he suffered with an injury to the left leg and had swelling of the limb.As the wound is not healing he was admitted in our hospital.

There was history of continuous fever for first3 days which was low grade and was relieved on medication.

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

PAST HISTORY:-

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

Known case of diabetes mellitus since 2 months and is on regular medication.

Not a known of CAD, hypertension, asthma,thyroid, tuberculosis.

SURGERIES:-

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

PERSONAL HISTORY:-

Diet:- mixed

Appetite:- normal

Bowel & bladder movements:- regular

Sleep:- inadequate since 2 days.

Patient has smoking habit since 15 yrs and smokes 3 packs daily and is an alcoholic since 15 years.

FAMILY HISTORY:-

The patient's family have similar compliants of diabetes.

No cancer deaths in the family.

TREATMENT HISTORY:-

Patient is not allergic to  any drugs.

GENERAL EXAMINATION:-

patient was cooperative,coherent and conscious

Patient looks obese and had bilateral pedal edema.

No pallor, icterus,cyanosis,clubbing,lymphdenopathy

VITALS:-

Temperature:-afebrile

SpO2:_95 %at room air

Pulse :- 103 bpm

Respiratory rate:- 18 cycles/ min

Bp:- 140/100

SYSTEMIC EXAMINATION:-

CVS:-

S1 & S2 heard

No murmers

Respiratory system:-

Trachea is in central position.

Normal vesicular breathing sounds are heard.

Abdomen:-

Obese abdomen

No tenderness

No palpable mass

Bowel sounds are heard.

CNS:-

Conscious

Speech:- normal

Gait:- normal

Cranial nerves normal

Sensory & motor system normal.

INVESTIGATIONS:-

hemogram

Hb:-10.4

TLC:-18000

Neutrophils :- 78

Esinophils:-2

Basophils:-0

Lymphocytes :- 10 

Monocytes:- 10

CUE- normal

SARS COVID- NEGATIVE

CHEST X- RAY:-

E 

ECG:-

 

URINE CULTURE:-

BLOOD CULTURE:-

CULTURE AND SENSITIVITY SWAB FROM THE WOUND:-

PROVISIONAL DIAGNOSIS:-

Left lower limb cellulitis with sepsis with known case of DM type 2 since 2 months with COPD,with OSA with hypokalemia with mild ARDS.

TREATMENT:-

_INJ .MEROPENAM 1g/iv/BD

_ INJ.CLINDAMYCIN 600mg/iv

_INJ.PAN 40mg/OD

_ INJ.ZOFER 4 mg/iv/tid

_ NEB.DUOLIN

5th hrly & BUDEEROT 12 th hrly

_ INJ LEVIPIL 500 mg/iv/BD

_ INJ.CLEXANE 40mg/sc/od

_IVF 1NS, 1 RL @75ml per hr

_2 egg whites per day

_ protien powder in one glass of milk /po/bd

TAB. PREGABALIN

TAB BENXL

NICOTINE CHEWING GUMS

_TAB SPOROLAC - DS po/BD

_TAB AMLONG - PO/OD

_TAB LEVIPIL - PO/OD

_ TAB CHYMEROL FORTE -PO/BD