General medicine Case 1

 GM Case history-1

August 10, 2021

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Date of admission:29-07-2021

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

HISTORY OF PRESENT ILLNESS:

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 an injury to his left leg and had swelling of that limb.As the wound was not healing,he was admitted in our hospital.

There was h/o continuous fever for the first 3 days when he was admitted in the hospital which was low grade and was relieved on medication.

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

PAST HISTORY:

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

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

Not a known case of CAD,Hypertension,Asthma,Tuberculosis.

SURGERIES:

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

PERSONAL HISTORY:

Patient has mixed diet with normal appetite and regular bowel and bladder habits.He had inadequate sleep since 2 days.

Patient has smoking habit since 15 years and smokes 3 packs per day and is an alcoholic since 15 years.

FAMILY HISTORY:

The patient’s family have a similar complaint of diabetes.

No cancer deaths in the family.

TREATMENT HISTORY:

The patient is not allergic to any known drugs.

GENERAL EXAMINATION:

Patient was conscious,coherent,cooperative.

Patient looks obese and has bilateral pedal edema.

No pallor,icterus,Clubbing,Cyanosis,Lymphadenopathy.

VITALS:

Temperature:afebrile

SpO2:95% at room air.

Pulse rate:103bpm

Respiratory rate:18 cycles/min

BP:160/100mm Hg.

SYSTEMIC EXAMINATION:

CVS:

S1 and S2 heard

No murmurs.

RESPIRATORY SYSTEM:

Trachea is in central position.

Normal Vesicular breath sounds heard.

ABDOMEN:

Obese abdomen

No tenderness

No palpable mass

Bowel sounds are heard.

CNS:

Conscious and normal speech.

Normal gait

Cranial nerves normal

Sensory and motor system normal.

INVESTIGATIONS:

HEMOGRAM:

Hb-10.4

TLC-18000

Neutrophils-78

Eosinophils-2

Basophils-0

Lymphocytes-10

Monocytes-10

CUE-normal.

SARS COVID-NEGATIVE

FEVER CHARTING:

CHEST X-RAY:

ECG:

BLOOD CULTURE:

URINE CULTURE:

CULTURE AND SENSITIVITY OF 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:

Proped up posture 

IV fluids 2NS and 1RL at 75ml/hr

Plenty of oral fluids

Intermittent CPAP 4th hourly

INJ.PAN 40mg/OD

INJ.HAI SC acc to GRBS

NEB.IPRAVENT and BUDECORT 8th hourly

INJ. CLEXANE 60mg SC/OD

INJ.PIPTAZ 4.5g/IV/TID

TAB.REDORIL 100mg PO/BD

TAB.PREGABALINE PO/H/S

TAB.BENXL PO/OD

NICOTINEX CHEWING GUMS

TAB.LEVIPIL 500mg PO/BD

TAB.DOLO 650mg PO/SOS

TAB. AMLONG 10mg PO/OD

SYP.POTCHLOR 15ml in 1 glass of water PO/OD

TAB. SPOROLAC DS PO/BD

ORS Satchet in 1 L water after passing each stools

3 egg white/day

Protein powder in 1 glass of milk/PO/BD(DIABETIC PROTEIN POWDER).