GM case 1

This is an online E log book to discuss our patient's deidentified 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 patient's 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 the comment box is welcome. 

A 60 yr old Man who is a government employee who does tree plantation came to the hospital with complaints of 

-left lower limb swelling ,fever, and pain since 11 days,

-shortness of breath at rest since 3 days 

-vomiting and Diarrhoea since 1 day .

HOPI :

 patient was apparently asymptotic 15 days back then he sustained thorn prick at the posterior Lower aspect of leg during his work . The thorn was removed .

*on 5 th day he developed swelling near the wound and the pain  was of  dragging type and he developed fever for which he visited the local RMP where he was given some injections.

But the symptoms were not relieved ,the swelling got gradually progressed till knee on 7 th day.

*So he visited to another RMP at Ramannapet on 7 th day there he was given some medications for 4 days . He developed Shortness of breath ,  on the 12th day and visited the same RMP, who referred to higher centre. 

*On 13 th day they went to Nalgonda Government hospital where the basic investigations were done and they were informed that serum creatinine and Urea were elevated and referred to Our hospital .They came to Casualty on 14 th day -11:00 pm with complaints of 

-shortness of breath even at rest(grade-4), vomiting-5 episodes and loose stools 4episodes since 1day

Past history-

k/c/o HTN since 1yr

No h/o DM,asthma ,TB,epilepsy 

Personal-

Diet -mixed 

Appetite-normal

Sleep-adequate 

Bowel and bladder-regular 

Addictions-alcohol occasionally 

Family-

no similar complaints 

Drug history -

Not allergic to any known drugs

•General physical examination-

Pt is conscious,coherent and cooperative moderately built, moderately nourished.

No signs of pallor,icterus ,cyanosis,clubbing,koilonychia,generalised lymphadenopathy,left sided pedal oedema 

Vitals: 

Afebrile, B.P : 140/80 mm of Hg , 

P.R : 80 bpm,

R.R : 18 cpm

Spo2 : 98% at RA

O/E

Oedema is extending till knee 

Skin is red,shiny,oedematous and has blisters 

Per abdomen: Soft, Non tender , No organomegaly,No palpable masses,Hernial orifices intact,Bowel sounds are heard 

CVS: S1, S2 to are heard , No murmurs are heard 

CNS:  HMF intact 

All cranial nerves intact 

Gait- normal

Motor system examination 

Bulk-N

Tone-N

Power-N

Reflexes-    Rt.              Lt

Biceps.        +2.              +2

Triceps.       +2.              +2

Supinator.    +2.              +2

Knee.           +2.              +2

Ankle.          +2.              +2

Plantar.       Flexion.      Flexion

Sensory system-normal

Cerebellar signs-intact

Respiratory system 

BAE present 

Normal vesicular breath sounds heard

No added sounds

Investigations : 

Day1 

 

 

 

On day 3 

  Diagnosis: 

Pre renal AKI With left leg cellulitis. 

Treatment: 

1.)Inj.Augmentin 1.2gm/I.V/B.D

2.)Inj.Metrogyl 500mg /I.V/ TID 

3.)Inj. Pan 40 mg /I.V/O.D

4.) Magnesium sulfate+ glycerine dressings 

5.)inj.lasix 40 mg/I.V/B.D

6.)I.V fluids-N.S -100ml/hr 

7.)Tab. Chymoral forte/P.O/TID