A 49 year old man with CKD & Left leg swelling

Medical case disscussion 


July 31,2022

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

Here we discuss our patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

This E log book also reflects my patient - centered online learning  portfolio and your valuable inputs inthe comment box are welcome.
Name : Mounika 8th 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


        CASE DISCUSSION

49yr old man contacter by occupation r/o nalgonda came to OPD with chief complaint of 
•Swelling in the right leg since 20days 
•Fever since 1 week.


History of presenting illness 
Patient was apparently asymptomatic 20days back then he developed
•Pain in the right lower limb and he went to Near by hospital  and was treated with antibiotics   
•He developed swelling in the lower limb  which is insidious in onset ,gradually progressive ,pitting type initially extended from ankle to knee  
•He developed a bubble like thing in the dorsum of the right foot which bursted and developed into an ulcer
•H/o fever since 1week which is intermittent associated with chills and rigors.
No h/o burning micturition decreased urine output


Daily routine 

Wakes up at 5am
Haves breakfast at 7am
Goes to work at 8 am 
Lunch at 1-2pm
Come back home by 5pm 
Dinner at 8pm
Sleeps at 11pm

Past History 

Diabetes since 12 yrs and using glimepiride 
Hypertenstion since 12yrs and is using nifidipine
No History of asthma, Epilepsy, Tuberculosis

Patient developed  shortness of breath 2yrs back and was diagnosed with heart disease (CAD)and renal disease and he was treated and symptoms subsided

•History of dialysis
1st on 22/7/22
2nd on 24/7/22
3rd time on 29/7/22

Personal History 

Diet-mixed
Appatite-normal
Sleep-adequate 
Decreased urine output(3 to 4 times a day)
Normal Bowel movements 
No addictions 
No known allergies 

Family History 
No significant 

Treatment history 

He is using ecosprin,furosemide,folic acid  since 2 yrs
And glicazide,nifidipine since 12yrs  daily morning 

General examination 
The patient was consious, coherrent, cooperative  Well oriented with time, place and person .well built and nourished 
No pallor, icterus, cyanosis, clubbing, lymphadenopathy
Pedal edema present
Vitals
temp-afebrile(98.6)
Bp-120/90mm of Hg 
PR-88bpm
RR-18cpm
Spo2-97%
GRBS-107mg/dl

                           Systamic examination 
Clinical pictures 
                                Investigations 
*X-Ray Chest - PA view
*CBP
*RFT
*LFT

*USG REPORT
*ECG

*ELECTROLYTES AND OTHER TESTS
Provisional Diagnosis : 
1. CHRONIC KIDNEY DISEASE
2. OLD CAD (IWMI)
3. POST COVID
4. Right Lower limb CELLULITIS -- Diabetic Foot             Ulcer
5. Recurrent-HYPOGLYCEMIA 2° to OHA(Resolved)
                    fever spike
                     Stool



TREATMENT:

Fluid and salt restriction
Tab.NICARDIA XL 30 mg /od
Tab.Bisoprolol 5mg /od
Tab.ecospirn 75/20mg
Tab.lasix 40mg
Tab.Nodosis 500mg/BD
Tab. Orofer xt /po/OD
T.BACT Ointment 
Regular dressing compressive crepe bandage.






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