A 58 year old male patient with SOB and fever with lower limb cellulitis

Patient Hi, This is G. Nandini a fifth semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from  patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them.  

A 5year old male patient farmer by occupation came to the old with short ness of breath (grade -4) since one day and fever. 

CHIEF COMPLAINTS:

 A 58 year old male patient farmer by occupation came with  chief complaints

*shortness of breath since one day and had a history of fall in washroom After which there is swelling in the  lower limb associated with pain and fever. 

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 7 yrs back then he went to checkup for fever then was diagnosed as Diabetic and aslo with hypotension and was taking medications since then.

Then after 2 yrs he developed ulcers on both the legs after an injury during the field work and there was skin peeling also.

Thereafter he was on a diet for 4 months {which includes drinking organic coconut oil,taking only liquid foods, Vegetables that made him lose his weight (100 to 75 kg)} was healthy but he developed skin infections (fungal) on the lower abdomen and legs and was on medications. 

After a year he developed muscle spasm in the left leg and back pain for which he took various unprescribed painkillers (for 2yrs).he also went for physiotherapy 5-6 months back.

3 months back he met with an RTA and had an left ankle injury which was non healing even on medication.

Patient was alcoholic at the age of 15-30 yrs and stopped drinking thereafter.

 8 yrs back he again started drinking alcohol due to depression after his son died and stopped when he developed leg ulcers(5 yrs back).

1yr back he consumed alcohol 2-3 times and stopped.

5 days back he started consuming toddy ( after dinner) daily for 3 days.First 2 days he was normal but on the 3rd day before going to sleep at night he started having shortness of breath ( grade 4 ), Sweating, fever and gas trouble.

He was treated by private practitioner on the same night but his condition was not improving so was shifted to the hospital.

PAST HISTORY:

k/c/o Diabetes since 7 years

K/c/o Hypertension

NO H/O   Tuberculosis,asthama, epilepsy, thyroid, CAD, CVD.No previous surgeries and blood transfusions. 

 

PERSONAL HISTORY:

He is married. 

 Mixed diet. 

Appetite :Normal

Micturtion: Normal

Bowel and bladder habits : Normal

 

Tobbaco - chewable

No other it'saddictions. 

FAMILY HISTORY:

Has no family h/o  HTN, TB, heart disease,cancers, epilepsy. 

Family h/o of DM (father) 

GENERAL EXAMINATION : 

Vitals :

• BP - 150/70 mmHg

• Temp. - 98.6°

• SpO2 - 93℅

• RR - 30 cycles/min

• PR - 160 bpm

•GRBS : 142 mg%

PALLOR : Absent

ICTERUS : Absent

CYANOSIS :Absent

CLUBBING :Absent

 

GENERALIZED LYMPADENOPATHY :Absent

Bilateral Edema is seen from thigh to toes (left more than right)

  

SYSTEMIC EXAMINATION :

CVS:

• S1, S2 heard

• No thrills and cardiac murmurs

RESPIRATORY SYSTEM:

• dyspnoea present 

* Nowheezing

• Postion of trachea - central

• Breath sounds - Vesicular

ABDOMEN:

• No tenderness, palpable mass, bruits

• No palpable liver and spleen

•Shape :Schapoid

CNS:

• Conscious and coherent

• Speech - normal

• No signs of meningeal irritation

PROVISIONAL DIAGNOSIS:

Sepsis secondary to lower limb cellulitis with metabolic acidosis. 

TREATMENT :

Treatment given on 6/7/22

1.Head end elevation upto 30 degree

2.O2 supplementation if spo2 is less than 90 percentage

3.Inj.PIPTAZ 2.25gm/IV/BD

4.Inj.METROGYL 100ml/IV/BD

5.Inj.HEPARIN 5000IU /IV/TID

6.Inj.Nor-Adr(2amp in 50ml)

7.Inj.PANTOP 40mg/IV/OD

8.Inj.NEOMOL 100ml (if temp greater than 101 degree Fahrenheit)

9.Inj.ZOFER 4mg /IV/SOS

10.Tab.CHYMORAL FORTE/PO/TID

11.Mgso4+ glycerine dressing daily

12.Foot end elevation

13.Inj.HAI /SC/ premeal(8am-2pm-8pm)

14.Monitering vitals hourly

15.Neb-Duolin and  Neb -budecort 8th hourly

16.GRBS charting 4th hourly

17.LULICONAZOLE oint

18.IV fluids 100ml/hr

ECG:

Fever chart:

Ultrasound report:

CBP,LFT,ABG Findings: