22 YEAR OLD FEMALE WITH LEFT LEG SWELLING

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Name - Mounika ,7th sem

Roll no - 46

I have been given this case to solve an attempt to understand the topic of "patient clinical analysis data " to develop my competency in reading and comprehending clinical data including clinical history,clinical findings, investigations and come up with a diagnosis and treatment plan

 22YEAR OLD FEMALE WITH LEFT LEG SWELLING 

A 22 year old female patient who's a daily labourer by occupation presented to the opd with  

●CHIEF COMPLAINTS... 

C/O   PAIN and SWELLING  in left limb below knee since 1 month.. 

●HISTORY OF PRESENT ILLNESS......

 The Patient was apparently asymptomatic 1year ago then she developed  round skin lesions  associated with itching ,went to local RMP doctor and used some topical ointment for period of 3-4 months  but patient did not get any relief , then again went to RMP  was prescribed with AVIL (anti allergic )and DECADRAN (dexamethasone )  injections and patient used them for a period of 3-4 months even then patient did not get relief from her skin lesions and then she came to our hospital and  was given ITRACONAZOLE  and her skin lesions were then subsided .

3 months ago  she had developed  fever then she underwent some investigations and was found to be diabetic and was on medication TAB.METFORMIN 500MG  OD and INJ. MIXTARD S/C 6U

H/o facial puffiness since 3 months .

Decreased urine output since 1 month .

  H/o pain in the left lower limb since 1 month denies history of trauma later on swelling appeared and was later associated with pus discharge and  underwent aseptic dressing for 1 week  but the swelling progressed and patient is unable to walk due to pain .

H/o fever since 2 weeks on and off subsiding on taking medication , associated with nausea .

No h/o vomiting ,loose stools . 

●PAST HISTORY...... 

Known case of  DM since 3 months on tab metformin 500mg and inj. Mixtard 6u ---x---x 

Not a known case of HTN, Asthma, Epilepsy , TB, CAD. 

 Underwent LSCS due to delayed labour. 

●PERSONAL HISTORY..... 

DIET :Mixed  

Appetite : decreased 

Bowels : c/o Constipation 

Micturition : Decreased urine output . 

No known allergies  

No addictions. 

● FAMILY HISTORY..... 

No significant family history . 

● MENSTRUAL AND OBSTETRIC HISTORY...

Menarche -13 years

6/30cycle

P1L1  -   LSCS.

●GENERAL EXAMINATION.... 

Patient was conscious , coherent, cooperative.

Moderately built and moderately nourished .Well oriented with time ,place and person  .NO  pallor ,icterus ,cyanosis ,clubbing ,lymphadenopathy 

Unilateral left lower limb edema  which is of pitting type . 

Vitals : 

Temp: 98.6  

BP- 100/70 mmhg 

PR- 92/min 

RR- 18/ min  

Spo2- 98% 

Grbs- 372mg% 

● SYSTEMIC EXAMINATION..... 

RS: BAE+,NVBS+ 

CVS:S1 S2 +no murmurs. 

CNS :No focal neurological  deficits. 

PA:SOFT ,NON TENDER,BOWEL SOUNDS+ 

INVESTIGATIONS:

●PROVISNAL DIAGNOSIS 

Iatrogenic Cushing's with h/o tenia corporis

K/c/o taenia corporis 

LEFT LOWER LIMB CELLULITIS WITH UNCONTROLLED DIABETES MELLITUS .

●TREATMENT

- IVF - NS , RL @100ML/HR

- INJ. PAN 40MG IV OD BBF

- INJ . NEOMOL 1GM IV SOS (IF TEMP> 101)

- INJ.HAI S/C TID 

- TAB. DOLO 650MG PO SOS 

- SYP . POTCHLOR 10 ML PO IN 1 GLASS OF WATER TID.