Long case:
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With reference
https://mvineelarollno90.blogspot.com/2023/11/65-y-female-with-co-fever-since-4-days.html
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 15 days back.
HOPI:
Patient was apparently asymptomatic 15 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.
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 foot 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.
Events:
K/c/o-CAD
2015,2018-underwent stenting
2020-CABG
K/c/o-obstructive sleep apnea,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
Underwent hysterectomy in 1997 and oophorectomy i/v/o fibroid
Personal history :
Appetite-Normal
Diet-Mixed
Bowels-Regular
Micturition -Normal
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
ULCER
FASCIOTOMY
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
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 and ulcer over dorsum of foot and right calf,grade 2 bedsore of B/Lgluteal region ,S/P dysarticulation of right 5th toe and debridement of ulcer and bed sore under S.A(POD2)
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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