36yr old male
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Name: K.G. Prasuna Reddy
Roll no. 59
I've 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 a diagnosis and treatment plan.
Following is the view of my case :
LOWER LIMB SWELLING AND FACIAL PUFFINESS SINCE 10DAYS
PT WAS APPARENTLY ASYMPTOMATIC THEN HE DEVELOPED FEVER FOR WHICH HE VISITED HOSPITAL WHERE HE WAS DIAGNOSED WITH DM AND WAS PUT ON OHAS FOR LAST 6 YRS AND THEN WAS SHIFTED TO INSULIN MORNING AND NIGHT 15 UNITS. THEN HE WAS FINE TILL 1 YR BACK WHEN HE DEVELOPED DECREASED URINE OUTPUT AND GENERALIZED BODY EDEMA FOR WHICH HE WAS ADMITTED TO A HOSPITAL AND WAS TOLD THAT HE HAS SOME KIDNEY PROBLEM, SAME TIME HE WAS DIAGNOSED WITH HTN AND WAS DISCHARGED WITH CLINIDIPINE AND DYTOR AND WAS FINE TILL 10 DAYS BACK AND STARTED DEVELOPING SWELLING AND ULCER IN RT FOOT ASSOC WITH FEVER , BOTH LL SWELLING AND FACIAL PUFFINESS
PERSONAL HISTORY:
APPETITE NORMAL
DIET MIXED
BOWELS REGULAR
DECREASED URINE OUTPUT
SLEEP ADEQUATE
NO KNOWN ALLERGIES
NO SIGNIFICANT FAMILY HISTORY
PALOR+, EDEMA+
NO ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY
VITALS:
TEMP: 99F
PR: 84BPM
RR: 18CPM
BP: 170/100MMHG
SPO2: 96%AT RA
LOCAL EXAMINATION:
AN ULCER OF 2×2×3CM IN WEBSPACE B/W GREAT AND 2ND TOE
LOCAL RISE OF TEMPERATURE AND TENDERNESS PRESENT
PUS DISCHARGE PRESENT
SYSTEMIC EXAMINATION:
CNS: NFND, HMF INTACT
SENSORY EXAMINATION:
SPINOTHALAMIC : UL AND LL ON RT AND LT
1. CRUDE TOUCH : NORMAL
2. PAIN : NORMAL
3. TEMPERATURE: NORMAL
POSTERIOR COLUMN: UL AND LL ON RT AND LT
1. FINE TOUCH: NORMAL
2. POSITION SENSE: 10/10
CORTICAL: UL AND LL ON RT AND LT
1.2 POINT DISCRIMINATION:
2. TACTILE LOCALIZATION : NORMAL
GRAPHESTHESIA: NORMAL
STEREOGNOSIS: PRESENT
CVS: S1,S2 HEARD
RS: BAE+
P/A : SOFT, NON-TENDER
INVESTIGATIONS:
PROVISIONAL DIAGNOSIS:
Diabetic foot, k/c/o dm since 10 yrs, on insulin since 4 yrs, htn since 1yr, ? Diabetic nephropathy ? Aki on ckd
with anemia secondary to ?ckd with HFEPF (53% EF)
TREATMENT:
17/12/22
INJ CLINDAMYCIN 600MG IV TID
INJ MONOCEF 1G IV BD
INJ HAI S/C ACC TO GRBS
TAB NODOSIS 500MG PO BD
TAB SHELCAL CT PO OD
TAB OROFER XT PO BD
TAB LIMCEE PO BD
TAB CINOD 10MG PO OD
GRBS MONITORING 6TH HRLY
BP MONITORING 4TH HRLY
18/12/22
INJ CLINDAMYCIN 600MG IV TID
INJ MONOCEF 1G IV BD
INJ HAI S/C ACC TO GRBS
INJ LASIX 40MG IV BD
TAB NODOSIS 500MG PO BD
TAB SHELCAL CT PO OD
TAB OROFER XT PO BD
TAB LIMCEE PO BD
TAB CINOD 10MG PO BD
GRBS MONITORING 6TH HRLY
BP MONITORING 4TH HRLY
19/12/22
INJ CLINDAMYCIN 600MG IV TID
INJ MONOCEF 1G IV BD
INJ HAI S/C ACC TO GRBS
INJ LASIX 40MG IV BD
TAB NODOSIS 500MG PO BD
TAB OROFER XT PO BD
TAB CINOD 10MG PO BD
TAB PRAZOSIN 5MG PO BD
INPUT OUTPUT CHARTING
GRBS MONITORING 6TH HRLY
BP MONITORING 4TH HRLY
20/12/22
D4 INJ CLINDAMYCIN 600MG IV TID
D4 INJ MONOCEF 1G IV BD
INJ HAI S/C TID 10-10-10U
INJ LASIX 40MG IV BD
TAB NODOSIS 500MG PO BD
TAB OROFER XT PO BD
TAB CINOD 10MG PO BD
TAB PRAZOSIN 5MG PO BD
INPUT OUTPUT CHARTING
21/12/22
D5 INJ CLINDAMYCIN 600MG IV TID
D5 INJ MONOCEF 1G IV BD
INJ HAI S/C TID 10-10-10U
INJ LASIX 40MG IV BD
TAB NODOSIS 500MG PO BD
TAB OROFER XT PO BD
TAB CINOD 10MG PO BD
TAB PRAZOSIN 5MG PO BD
FLUID (<1 L/DAY) AND SALT (2G/DAY) RESTRICTION
INPUT OUTPUT CHARTING
D5 INJ MONOCEF 1G IV BD
INJ HAI S/C TID 10-10-10U
INJ LASIX 40MG IV BD
TAB NODOSIS 500MG PO BD
TAB OROFER XT PO BD
TAB CINOD 10MG PO BD
TAB PRAZOSIN 5MG PO BD
FLUID (<1 L/DAY) AND SALT (2G/DAY) RESTRICTION
INPUT OUTPUT CHARTING
22/12/22
D6 INJ CLINDAMYCIN 600MG IV TID
D6 INJ MONOCEF 1G IV BD
INJ HAI S/C TID 10-10-10U
INJ LASIX 40MG IV BD
TAB NODOSIS 500MG PO BD
TAB OROFER XT PO BD
TAB CINOD 10MG PO BD
TAB PRAZOSIN 5MG PO BD
TAB TELMA 40MG PO OD
FLUID (<1 L/DAY) AND SALT (2G/DAY) RESTRICTION
INPUT OUTPUT CHARTING
D6 INJ MONOCEF 1G IV BD
INJ HAI S/C TID 10-10-10U
INJ LASIX 40MG IV BD
TAB NODOSIS 500MG PO BD
TAB OROFER XT PO BD
TAB CINOD 10MG PO BD
TAB PRAZOSIN 5MG PO BD
TAB TELMA 40MG PO OD
FLUID (<1 L/DAY) AND SALT (2G/DAY) RESTRICTION
INPUT OUTPUT CHARTING
23/12/22
D7 INJ CLINDAMYCIN 600MG IV TID
D7 INJ MONOCEF 1G IV BD
INJ HAI S/C TID 10-10-10U, NPH 6-0-6
INJ LASIX 40MG IV BD
TAB NODOSIS 500MG PO BD
TAB OROFER XT PO BD
TAB CINOD 10MG PO BD
TAB PRAZOSIN 5MG PO BD
TAB TELMA 40MG PO OD
FLUID (<1 L/DAY) AND SALT (2G/DAY) RESTRICTION
INPUT OUTPUT CHARTING
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