A 71 year old male with complaints of loss of consciousness 30 mins back
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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 coming up with diagnosis and treatment plans. is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardians' signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.
MED CASE :-
A 71 year old male patient came to the casuality with the complaints
- Swelling to the right leg since 6 days
- loss of consciousness 30 mins back.
HISTORY OF PRESENTATING ILLNESS :-
A 71 years old male patient was apparently well 5 days back, patient had injury to right leg - thorn prick followed which patient developed swelling and pain right leg.
H/o decreased urine output consulted locally, evaluated found to have increased TLC and increased serum creatinine( 7.0 mg/dl) , He was initially evaluated outside where US doppler of both lower limb showed right lower limb cellulitis with no DVT.
USG abdomen showed Bilateral grade I RPC changes.
Then he was referred to a higher centre
There he was hypotensive ; fluid resuscitation done and started on vasopressor support.
And ABG Was sent and ABG showed severe metabolic acidosis. And he was Started on IV Antibiotics Inj. Meropenam and Inj. Teicoplanin, Inj. Metrogyl) and other medication. And was adviced for hemodialysis in view of severe metabolic acidosis. SLED ( Sustained low-efficiency dialysis ) was done for 8 hours.
And for the swelling of the right leg debridement was done .
And then due to some financial issues they thought of shifting the patient to other hospital and when he was being shifted to our hospital then patient lost his consciousness for 15 mins
With sweating and way bought here.; and primary resuscitation was done .
no c/o decreased urine output
no c/o fever, soB, palpitation, chest pain, orthopnea.
PAST HISTORY:-
Known case of DM TYPE 2 since 15 years and on medication METFORMIN 500 mg since then
( OD) .
15 years back patient had an episode of loss of consciousness and was investigated to find diabetes mellitus ( type 2) and is on med since then
Not a known case of HTN; CAD; CVA ; Thyroid ; TB ; asthma epilepsy
Allergic history:- No history of any kind of allergies for food/drugs
Family history:- no significant family history
GENERAL EXAMINATION:-
At the time of examination 3/9/23:-
PATIENT IS CONSCIOUS COHERENT AND CO OPERATIVE
NO PALLOR ; ICTERUS; CLUBBING; CYANOSIS; ODEMA ; LYMPHADENOPATHY
TEMPERATURE:- AFEBRILE
PR:98bpm
BP:140/80mmhg
RR:18cpm
CVS:S1 S2+,NO MURMURS
RS:BAE+ ; NVBS ; No added sounds
P/A:SOFT ; NON TENDER ; NO ORGANOMEGALY
CNS :-
Tone
Right Left
U.L N. N
L.L. N. N
Power
Right Left
U.L 5/5. 5/5
L.L. 5/5. 5/5
Reflexes
Right left
B ++. ++
T. ++. ++
S. ++ ++
K. ++
A. +
Planter - right can not be elicited
Left flexor
PROVISIONAL DIAGNOSIS:-
AKI SECONDARY TO SEPSIS WITH RIGHT LOWER LIMB CELLULITIS WITH KNOWN CASE OF DM TYPE II SINCE 15 years
INVESTIGATIONS:-
HAEMOGLOBIN
11.2
TOTAL COUNT
23,300
NEUTROPHILS
89
LYMPHOCYTES
06
EOSINOPHILS
01
MONOCYTES
04
BASOPHILS
00
CV
31.9
MCV
90.6
MCH
31.8
MCHC
# 35.1
RDW-CV
14.2
RDW-SD
47.8
RBC COUNT
3.52
PLATELET COUNT 96,000
SERUM MAGNESIUM:- 1.8
CUE :-
Albumin :- ++
Sugars :- nil
Pus cells :- 6-8
RFT :-
Urea :- 158
Creatinine:- 4.2
Uric acid :- 1.9
Sodium :- 135
Potassium:- 3.0
Chloride :- 98
Total Bilirubin 2.69
Direct Bilirubin 0.87
SGOT(AST) 72
SGPT(ALT) 32
ALKALINE PHOSPHATE 274
TOTAL PROTEINS :- 4.5
USG :-
GRADE I Fatty liver
Raised echogenecity of bilateral kidneys
X RAY :- chest PA VIEW
FINAL DIAGNOSIS:-
AKI SECONDARY TO SEPSIS WITH RIGHT LOWER LIMB CELLULITIS WITH KNOWN CASE OF DM TYPE II SINCE 15 years
TREATMENT GIVEN :-
Dialysis was done on 3/9/23 in our hospital
REGULAR DEBRIDEMENT AND DRESSING;
- Iv fluids U.O+ 30 ml/hr
- INJ. PIPTAZ 2.25 gM IV / BD
- INJ. METROGYL. 500 mg IV/ TID
- HUmAN ACTRAPID INSULIN
S/C TID before MEAL
5. INJ . LASIX 40 mg IV/BD
(IF SBP > 110 mmHg )
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