42 YR OLD MALE PRESENTED WITH WOUND OVER POSTERIOR ASPECT OF RIGHT FOOT SINCE 6 MONTHS AND SWELLING OF RIGHT LOWER LIMB

 Case History and Clinical Findings

42 YR OLD MALE PRESENTED WITH WOUND OVER POSTERIOR ASPECT OF RIGHT FOOT SINCE 6 MONTHS AND SWELLING OF RIGHT LOWER LIMB SINCE 7 DAYS

HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 6 MONTHS BACK HE HAD WOUND OVER POSTERIOR ASPECT OF RIGHT FOOT, DONE THE REGULAR DRESSING AT THE HOSPITAL AND GRADUALLY PROGRESSED TO PRESENT STATE AND LATER DEVELOPED SWELLING OF RIGHT LOWER LIMB BELOW KNEE SINCE 7 DAYS- INSIDIOUS ONSET, GRADUALLY PROGRESSED FROM ANKLE TO KNEE

H/O PURULENT DISCHARGE FROM THE WOUND SINCE 1 DAY

NO H/O TRAUMA

C/O FEVER FOR 1 WEEK AND SUBSIDED 3 DAYS BACK ASSOCIATED WITH CHILLS, BODY PAINS,VOMITING(2 EPISODES/DAY) FOR 3 DAYS RELIEVED ON MEDICATION.

H/O POLYURIA, NOCTURIA

NO H/O POLYDIPSIA, POLYPHAGIA

NO H/O BURNING MICTURITION, PEDAL EDEMA

PAST HISTORY:

K/C/O TYPE 2 DM SINCE 10 YEARS(TAB. METFORMIN 1000MG IN DAY AND 500MG IN NIGHT)

NOT A K/C/O HTN/TB/ EPILEPSY/CVA/CAD/ASTHMA

H/O HEMORRHOIDS SURGERY 10 YEARS BACK

PERSONAL HISTORY:

DECREASED APPETITE SINCE 1 WEEK

TAKES MIXED DIET

BOWELS HABITS ARE REGULAR

POLYURIA PRESENT

CHRONIC ALCOHOLIC SINCE 20 YEARS

GUTKA CHEWING SINCE 20 YEARS

GENERAL EXAMINATION:

PATIENT IS C/C/C

NO SIGNS OF PALLOR, ICTERUS,CYANOSIS, CLUBBING, LYMPHADENOPATHY

PEDAL EDEMA OF RIGHT LOWER LIMB TILL KNEE PRESENT

VITALS:

TEMP: AFEBRILE

PR: 96 BPM

RR: 20 /MIN

BP: 140/90 MM HG

GRBS- 550 MG/DL

SYSTEMIC EXAMINATION:

CVS: S1 S2 HEARD

RS: BILATERAL AIR ENTRY PRESENT

CNS: NFND

P/A: SOFT, NON TENDER, NO ORGANOMEGALY

BOWEL SOUNDS HEARD

COURSE IN HOSPITAL:

GENERAL SURGERY REFERRAL WAS TAKEN I/V/O ULCER OVER RIGHT HEEL ON 15/3/23 AND DIAGNOSED WITH CHRONIC NON HEALING ULCER ?MARJOLINS ULCER ?VERRUCOUS CARCINOMA WITH RIGHT HYDROCOELE

ON 16/3/23:

WEDGE BIOPSY WAS DONE FROM THE ULCER OVER THE RIGHT HEEL AFTER TAKING INFORMED CONSENT AND SENT TO HPE

PROCEDURE WAS UNEVENTFUL

PRE AND POST BIOPSY VITALS ARE STABLE

OPHTHALMOLOGY OPINION WAS TAKEN I/V/O DIABETIC RETINOPATHY: ANTERIOE SEGMENT AND FUNDOSCOPY ARE WITHIN LIMITS. NO DIABETIC RETINOPATHIC CHANGES NOTED. ADVISED FOR FUNDOSCOPY FOR EVERY 6 MONTHS

ON 18/3/23:

ORTHOPAEDIC OPINION WAS TAKEN I/V/O ANY BONY INVOLVEMENT AND ADVISED X RAY OF FOOT WITH ANKLE- AP, LATERAL VIEW, WAS DONE ON 20/3/23. THE REPORT IS AS FOLLOWS:

COMMINUTED AND DISPLACED FRACTURE OF BODY OF CALCANEUM AND SOFT TISSUE THICKENING OF RIGHT FOOT

ON 20/3/23

PLASTIC SURGERY OPINION WAS ADONE AS ADVISED BY GENERAL SURGERYE DEPARTMENT, THEY ADVISED VAC DRESSING, PAC

ON 21/3/23:

CASE WAS REVIEWED BY ORTHOPEDICS DEPARTMENT AND WAS DIAGNOSED RIGHT CALCANEAL FRACTURE AND RIGHT CALCANEAL OSTEOMYLIETES AND ADVISED ARTERIAL DOPPLER STUDY OF LEFT FOOT WHICH WAS NORMAL, X RAY HEEL LATERAL AND AXIAL VIEWS

ON 22/3/23:

1 UNIT OF PRBC TRANSFUSION WAS DONE I/V/O BLOOD LOSS DURING DEBRIDEMENT AND DAILY DRESSING AND LOW HB

ON 23/3/23:

CASE WAS REVIEWED BY ORTHOPEDICS DEPARTMENT, PATIENT WAS COUNSELLED FOR BELOW KNEE AMPUTATION FOR WHICH TH EPATIENT REFUSED, THEY REPORTED THAT SURGICAL INTERVENTION IS DEFFERED I/V/O POOR SKIN CONDITION AND SKIN FLAP IS NOT POSSIBLE. THEY ADVISED VACCUM ASSISTED WOUND THERAPY WITH POOR CHANCES OF WOUND HEALING

CASE WAS REVIEWED BY ORTHOPAEDIC DEPARTMENT

REPEAT WEDGE BIOPSY WAS DONE OVER THE WOUND OF RIGHT FOOT AFTER TAKING INFORMED CONSENT AND WAS SENT TO HPE

PROCEDURE WAS UNEVENTFUL

PRE AND POST BIOPSY VITALS ARE STABLE

ON 24/3/23:

VAC DRESSING WAS DONE

Provisional Diagnosis:-

DIABETIC KETOACIDOSIS(RESOLVED) WITH RENAL AKI(RESOLVED) WITH DIABETIC ULCER(ENTEROCOCCUS +) OVER LATERAL AND DORSAL ASPECT OF RIGHT FOOT+ULCERATIVE GROWTH OVER MEDIAL ASPECT OF RIGHT FOOT WITH RIGHT HYDROCOELE WITH COMMUNITED AND DISPLACED FRACTURE OF BODY OF RIGHT CALCANEUM AND RIGHT CALCANEAL OSTEOMYLIETIS WITH CORONARY ARTERY DISEASE(OLD) WITH DM(10 YEARS) DENOVO HTN WITH MILD IRON DEFICIENCY ANEMIA AND REACTIVE THROMBOCYTOSIS

S/P 1 UNIT PRBC TRANFUSED ON 22/3/23

Investigation:-

ON 15/3/23

HB- 10.7, TLC-17,300, PLT-3.58

ON 17/3/23

HB- 10.7, TLC-17,300, PLT-4.1

ON 18/3/23

HB- 9.5, TLC-15,500, PLT-4.1

ON 19/3/23

HB- 9.6, TLC-13,700, PLT-4.8

ON 20/3/23

HB- 8.9, TLC-10,500, PLT-5

ON 21/3/23

HB- 7.4, TLC-9,900, PLT-5.56

ON 22/3/23

HB- 8.1, TLC-11,300, PLT-7.7

ON 23/3/23

HB- 8.5, TLC-13,000, PLT-9.0

ON 24/3/23

HB- 7.9, TLC-11,000, PLT-8.9

ON 25/3/2023

HB:- 8.1 TLC:- 8500 PLT:- 9 LAKHS

ON 26/3/2023

HB:- 8.9 TLC :- 9700 PLT:- 9.3 LAKHS

ON 27/3/23

HB: 8.0, TLC-7,600, PLT-9.O LAKHS

BLOOD AND URINE CULTURE AND SENSITIVITY: SHOWED NO GROWTH

PUS CULTURE AND SENSITIVITY: ENTEROCOCCUS ISOLATED AND IS SENSITIVE TO VANCOMYCIN AND LINEZOLID

ARTERIAL COLOR DOPPLER OF BOTH LOWWER LIMBS: NO DVT AND OTHER ABNORMALITIES DETECTED

USG INGUINO SCROTAL REGION:

E/O EDEMATOUS SPERMATI C CORD NOTED(R.L)- FUNICULITIS

B/L EPIDYDIMIS AND TESTIS- NORMAL SIZE AND ECHOTEXTURE AND INCRESED VASCULARITY LIKELY ORCHITIS

E/O FREE FLUID AND INTERNAL ECHOS NOTED IN LEFT SCROTA SAC- MILD LEFT HYDROCOEL

E/O ENLARGED INGUINAL LYMPH NODES- LARGEST MEASURING 15 MM ON THE RIGHT

USG ABDOMEN- RAISED ECHOGENICITY OF BILATERAL KIDNEYS

HPE OF BIOPSY TAKEN ON 16/3/2023- ADVISED FOR REPEAT SAMPLE- REPORT AWAITED

2D ECHO-

EF: 64%

TRIVIAL TR, AR PRESENT. NO MR

NO RWMA, NO MS/AS

GOOD LV SYSTOLIC FUNCTION

DIASTOLIC DYSFUNCTION PRESENT, SCLEROTIC AV

NO PAH, PE

ECG;-

Treatment Given:-

INJ. HAI- 6UNITS IV/STAT

INJ. HAI INFUSION 1ML IN 39 ML NS AT 6 ML/HR. THE RATE WAS INCRESED OR DECRESED ACCORDING TO GRBS AND WAS STOPPED ON 18/3/23

1ST DAY REQUIREMENT- 72 UNITS

LAST DAY REQUIREMENT- INJ. HAI- 10 UNITS S/C/ TID

INJ. NPH- 8 UNITS S/C/ BD

IV FLUIDS- O/9 % NS 1 LIT IN 1ST HOUR

500 ML PER HOUR IN NEXT 2 HOURS

250 ML PER HOUR AND THE RATE WAS ADJUSTED SO THAT 6 LIT OF FLIUDS IS GIVEN IN 24 HOURS

IV FLUIDS- FLUSODEX 100 ML/HOUR X 2 DAYS

- NS X 9 DAYS

INJ. METROGYL 500 MG IV/TID FOR 7 DAYS

INJ. PIPTAZ 4.5 GM IV/TID FOR 4 DAYS STOPPED AFTER CULTURE REPORT

INJ.PAN 40 MG IV/OD

INJ. NEOMOL 1GM IV/SOS

TAB. LINEZOLID 600 MG PO/BD X 4 DAYS

TAB. CINOD 10 MG PO/OD X 11 DAYS AFTER DIAGNOSIS OF DENOVO HYPERTENSION

TAB. PCM 650 MG PO SOS

REGULAR ASEPTIC DRESSING DONE

2-3 EGG WHITES / DAY

STRICT DIABETIC DIET