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long case 2

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.                                                                                     
With the help of our senior
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 to casualty with C/O fever since 4 days,Shortness of breath since 2 days,pedal edema since 2 days.

HOPI 
Patient was apparently asymptomatic 2days ago then she developed SOB of grade 3 of insidious onset,gradually progressive associated with fever of high grade associated with chills and rigors. 
No H/O cough,sore throat.
Pedal edema present ,ulceration over right foot associated with pain and swelling present .
No h/O abdominal pain,loose stools,vomitings nausea.

Patient was apparently asymptomatic 1month back ,then she applied hot fomentation over right foot ,later she developed blisters over right foot which eventually got Burst and formed an ulcer, swelling of right lower limb since 4 days insidious in onset and non progressive associated with fever, SOB 




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 SINCE 11 MONTHS ON BIPAP 

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 









Vitals-
PR-85bpm
RR-16cpm
BP-160/100mm hg
GRBS-286 mg/dl

Systemic examination 
CVS-S1,S2 heard no murmurs
P/A-soft,NT,no organomegaly 
RS-BLAE +,NVBS
CNS

ULCER 




FASCIOTOMY 



GRADE 2 BED SORE




CANDIDIAL INTERTRIGO 






Investigations 

15/11/23

RBS-296mg/dl

Serum magnesium-2mg/dl

TROPONIN-I-146pg/ml





16/11/23

Urine for ketone bodies-negative 

Troponin -I-159.0pg/ml





ABG AT 11AM


ABG AT 3PM


Blood grouping and Rh typing-O positive 

PT-17 sec 

INR-1.25

APTT-34 SEC

ABG AT 6PM

ABG AT 12PM



17/11/23




ABG at 11am



ABG at 7pm


ABG at 9pm



18/11/23

ABG at 9am 


ABG at 12am 


19/11/23

ABG AT 8AM 


20/11/23




ABG AT 7AM

ABG AT 6:3OAM


TROPONIN -I-1,180 pg/ml


 
ABG AT 8:30AM 


21/11/23

ABG AT 8AM

ABG AT 10AM


22/11/23

ABG AT1AM



ABG AT 9AM


23/11/23

ABG AT 7AM 



BT-2MIN 00 SEC
CT-4MIN 30 SEC

APTT-33SEC

PT-17SEC
INR-1.2

24/11/23

At  7am 



At 9pm


PT-17SEC

INR-1.2

FBS-196MG/DL

25/11/23



26/11/23

27/11/23






28/11/23


LFT from 15/11/23 to 28/11/23


HEMOGRAM from 15/11/23 to 23/11/23


RFT 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.
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 

Ulcer dressing done

Current updates


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