35M type2DM for 10yrs on insulin since 7yrs HTN CKD since 2yrs

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 I have 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 diagnosis and treatment plan.

CASE HISTORY

C/O of fever since one week high grade on and off

 Vomitings since 4days(5-6 episodes/day)

Nausea +

Swelling of Left Lower Limb since 4days(thigh to calf)

Pain+, local rise of temperature+

HOPI-

Patient was apparently asymptomatic one week back then had fever which is of high grade associated with chills and rigors, relieved only on medication no evening raise of temperature, no cold,cough , fever continous. 

C/O vomitings since 4days - 4-6 episodes/day, content- food,non-bilious,non-projectile,no blood associated with nausea and swelling of left lower limb since 4days with pain and local rise of temperature. No C/O burning micurition, loose stools 

C/O of decreased urine output 

PAST HISTORY- 

K/C/O DM2 since 10years(using inj. mixtard-12U-x-8U)

K/C/O HTN since 2years (using Tab. Nicardia 10mg/TID)

K/C/O CKD since 2years on conservative managment 

S/P H/O Rays amputation if Right toe (great)

H/O 3 blood transfusions in February.

PERSONAL HISTORY 

APPETITE NORMAL

DIET MIXED

BOWELS REGULAR

DECREASED URINE OUTPUT

SLEEP ADEQUATE

NO KNOWN ALLERGIES 

NO SIGNIFICANT FAMILY HISTORY 

Clinical Images-

GENERAL EXAMINATION 

Patient is C/C/C

BP-110/80mmHg

PR-80bpm

RR-18cpm

GRBS-111mg/do

Temperature- 100 F

Spo2-99% on Room Air

SYSTEMIC EXAMINATION 

CVS- S1S2+,NO MURMURS

RS- BAE+,NVBS HEARD

P/A- SOFT,NON TENDER,BOWEL SOUNDS+

CNS- ORIENTED TO TIME,PLACE AND PERSON

INVESTIGATIONS 

HEMOGRAM-

USG findings

Grade 1 RPD changes noted in B/L kidneys

Urinary bladder shows irregular wall thickening likely cystitis

Gallbladder with Edema

Umbilical hernina omentum as content

Mild ascites.

Blood Culture(10/05/23)

No growth after 24hrs of aerobic inoculation

Culture from wound(11/05/23)

Methicillin senstive

Senstive to clindamycin, cotrimoxazle and E. Coil isolated

(Satohyloccus ) gentamycin 

Urine for C/S(11/5/23)

1-2 pus cells are seen.

Klebesilla pnemonia 10*5>CFU/ml of urine isolated

 

Diagnosis-

 

Sepsis secondary to Left Lower Limb Cellulitis(resolving) with Heart Failure With Mid Range Ejection Fraction(48%)

With Acute Kidney Injury(resolving)on Chrnoic Kidney Diease With Anemia(Normocytic Normochomic) due to?CKD

With Thrmobocytopenia(resolving)with K/C/O HTN since 2yrs 

S/P Rays Amputation of Great Toe( February)

S/P Fasciotomy Left Foot(13/5/23)

3 sessions of Hemodialysis were done.

TREATMENT GIVEN

1. IV Fluids NS@75ml/hr

2.Inj. Pan40mg IV/BD

3.Inj. Vitocofol 1500mg IM/BD

4.Inj. Thiamine 200mg in 100 mL NS IV/BD

5.Inj.Monocef 1gm IV/BD

6.Inj. Lasik 40 mg BD

7.Inj . HAI SC/TID acc. To GRBS

8.INj. Neomol 1gm IV/BD

9. Tab . Nodosis 500 mg PO/BD

10.Tab. Ultracet 1/2 PO/QID

11.Tab. Orofer-XT app/OD

12.Syp. Potklor PO/TID 10ml

13.Inj. Peptaz 2.25gms IV/TID

14.Inj. Clindamycin 600mg/IV/BD

15.Inj. Metrogyl 500 mg/IV/BD

16.Tab. Sporolac-DS PO/TID

17. GRBS 7. Profile Monitoring 

18.2-3 Eggs whites/day

19.Strict I/O charting

20. Monitor Vitals 2nd hrly., 2PRBC transfusion was done

ADVICE AT DISCHARGE 

1. Tab. AGUMENTIN 25MG PO/BD -4days

8AM- 8PM

2.Tab. CLINDAMYCIN 30MG PO/BD-4days

8AM-8PM

3.Tab. METRONODAZOLE 400MG PO/TD-4days

4.Tab. THIAMINE 200mg

5.Tab. LASIX 400 MG PO/BD-4days

8AM-8PM

6.Tab. PANTOPRAZOLE PO/BD- 4days

Before Food

7.Tab . NODOSIS 500mg PO/BD

8AM-8PM