A 50 Yr old male patient


This is online E log book to discuss our patient’s de-identified identified health data shared after taking his/her/guardian’s signed informed consent. 

Case

A 50 Yr old male patient with infected wound on right side of the thigh admitted in surgery referred to medicine i/v/O low hemoglobin 

History of presenting illness :

Patient was apparently asymptomatic 3 months ago when he met with an accident 
Injury to his right thigh
Went to local hospital got stitches done over the injury
After 1 Month 15 days the wound got infected. Patient was taken to nalgonda. 
Drained abscess from the wound
Due to spread of infection, incision was extended over the thigh
After Around 15 days later he developed anuria
1st dialysis was done in October in view of serum creatinine 2.5mg/dl. 
3 dialysis were done. He developed bradycardia. 
He went Hyderabad were 3 dialysis are done
After 1 Month he came to hospital for skin graft and anemia 

History of past illness :

Diabetes since 15 years on medication gliclazide and metformin
Hypertension since 3 months on medication amlodipine

Treatment history :

History of blood transfusion 

Personal history :

Married
Normal appetite 
Mixed diet
Regular bowel
No known allergies
Addictions : regular alcohol intake since 20yrs ( 1 quarter), last alcohol intake was 3 months back

Family history :

H/O Diabetes brother - on medication 
H/O Hypertension Father - on medication 

General examination  :

Pallor +
No icterus, cyanosis, clubbing, lymphadenopathy
Oedma of feet 





Vitals

Temperature - afebrile
Pulse rate - 76/min
Respiratory rate - 18/min
BP- 130/80 mmHg
SPO at room air - 98%

Systemic examination :

CVS system

No thrills
Cardiac sounds are heard
No cardiac murmurs

Respiratory system

No dyspnoea 
No wheeze
Trachea is centrally positioned 
Vesicular breath sounds
No adventitious sounds 

Abdomen 

Scaphoid shape abdomen 
No tenderness, palpable mass
Normal hernial orifices
Non palpable liver, spleen
No free fluid 
Bowel sounds heard

CNS

Conscious and alert
Normal speech 
No signs of meningeal irritation
Reflexes 
                    Right     Left
Biceps           +2         +2
Triceps          +2         +2
Supinator      + 2       +2
Ankle             +2          +2

Diagnosis :

Anemia under evaluation with ulcer over right thigh with k/c/o diabetes mellitus with k/c/o AKI (6 sessions of haemodialysis done) 

Investigations :

                                Day 3


USG
 

ECG








Day - 5
Opthalmology - mild hypertensive retinopathic changes

Treatment :

Day 1

-no iv fluids
- 1 PRBC transfusion
- Tab ZINCOVIT po/od
- BP, Pr, SpO2 monitoring 8th hourly 

Day 2

- No iv fluids
- 1 PRBC transfusion
- Tab ZINCOVIT po/od
- BP, Pr, SpO2 monitoring 8th hourly
- Tab VILDAGLIPTIN + METFORMIN 50/500 Po/od
- Tab GLICLAZIDE + METFORMIN 80/500 1/2 Po/od

Day 3

- No iv fluids
- Tab ZINCOVIT po/od
- BP, Pr, SpO2 monitoring 8th hourly
- Tab VILDAGLIPTIN + METFORMIN 50/500 Po/od
- Tab GLICLAZIDE + METFORMIN 80/500 1/2 Po/od
- GRBS charting 6th hourly

Day 4  

- No iv fluids
- Tab ZINCOVIT po/od
- BP, Pr, SpO2 monitoring 8th hourly
- Tab VILDAGLIPTIN + METFORMIN 50/500 Po/od
- Tab GLICLAZIDE + METFORMIN 80/500 1/2 Po/od
- GRBS charting 6th hourly
- PRBS Transfusion





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