Long case 2 (1/12/2023)

 mvineelarollno90

[Case Based OSCE ]65 Y female with C/O fever since 4 days, SOB since 2 days,pedal edema since 2 days

November 20, 2023

 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.                                                                                     


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 C/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

ULCER 




FASCIOTOMY 



GRADE 2 BED SORE



CANDIDIAL INTERTRIGO 







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 stat


CURRENT UPDATE









             

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