A 65 YR OLD FEMALE PRESENTED WITH C/O FEVER, SHORTNESS OF BREATH , PEDAL EDEMA,PAIN IN RIGHT LOWER LIMB

 Case History and Clinical Findings :

A 65 YR OLD FEMALE PRESENTED WITH C/O FEVER SINCE 4 DAYS, SHORTNESS OF BREATH SINCE 2 DAYS, PEDAL EDEMA SINCE 2 DAYS,PAIN IN RIGHT LOWER LIMB SINCE 2 DAYS

 SOB GRADE III

 PAST HISTORY:-  K/C/O HTN SINCE 10 YRS ON TELMA 40MG, TAB MET X L TRIO

 DM TYPE II SINCE 3 YRS ON INJ MIXTARD SC 40U 

 K/C/O CAD - S/P CABG IN 2020

 GENERAL EXAMINATION : PT IS C/C/C PALLOR PRESENT

 PEDAL EDEMA PRESENT 

 NO SIGNS OF ICTERUS , CYANOSIS, CLUBBING, LYMPHADENOPATHY

 TEMP : AFEBRILE

 BP: 150/80MMHG 

PR: 86BPM RR:

 18 CPM 

SYSTEIMIC EXMINATION:

 CVS S1 S2 HEARD 

 CNS : NO FOCAL NEUROLOGICAL DEFECITS

 RS: BAE PRESENT NVBS

 P/A : NO SINUSES MOVING ACCORDINGLY WITH RESPIRATION NO VISIBLE   PULSATIONS  ,NO PALPABLE SWELLINGS NO ORGANOMEGALY 

 BOWEL SOUNDS HEARD.

 PULMONOLGY REFERRAL DONE I/V/O COUGH, SOB ADVISED- TAB. ACEBROPHYLINE 100MG BD

 NEB WITH IPRAVENT 6TH HRLY

 BUDECORT 8TH HRLY

 TAB PCM 650MG TID 

 O2 INHALATION WITH 1-2 LIT/MIN ,MAINTAIN SPO2 % >94% 

SURGERY REFERRAL :-

DONE I/V/O RT LOWER LIMB CELLULITIS, BEDSORE,GANGRENE OF 5TH TOE

TREATMENT- TAB . CHYMEROL FORTE 10MG PO TID MGSO4 +GLYCERINE DRESSING, AIR BED

DISARTICULATION OF RIGHT5 TH TOE WITH DEBRIDEMENT OF ULCER AND BEDSORE UNDER SA DONE ON 24/11/23 

DVL REFERRAL I/V/O ITCHY SKIN LESIONS OVER GROIN AND INNER THIGHS

TREATMENT- CLOTRIMAZOLE 1% CREAM L/A BD X 1 WEEK 

ABZORB DUSTING POWDER L/A BD X 2 WEEKS 

COURSE IN THE HOSPITAL:-

A 65 YR OLD FEMALE PRESENTED WITH C/O FEVER SINCE 4 DAYS, SHORTNESS OF BREATH SINCE 2 DAYS, PEDAL EDEMA SINCE 2 DAYS, SOB GRADE III AND ON FURTHER INVESTIGATIONS DIAGNOSED WITH TYPE II DIABETES MELLITUS ,HYPERTENSION .K/C/O CAD S/P CABG IN 2020,ACUTE KIDNEY INJURY ,GANGRENE OF 5TH TOE, ULCER OVER DORSUM OF FOOT &RT CALF,GRADE II BEDSORE OF B/L GLUTEAL REGION S/P DISARTICULATION OF 5TH RT TOE &DEBRIDEMENT OF ULCER &BEDSORE UNDER SA ,CANDIDIAL INTERTRIGO +FRICTIONAL DERMATITIS. S/P 9 SESSIONS OF HEMODIALYSIS DONE , 4 BLOOD TRANSFUSIONS DONE PATIENT IS MANAGED CONSERVATIVELY WITH ANTIBIOTICS AND PLANNED FOR DISCHARGE .


Provisional Diagnosis:-

TYPE II DIABETES MELLITUS

HYPERTENSION

K/C/O CAD S/P CABG IN 2020

ACUTE KIDNEY INJURY

GANGRENE OF 5TH TOE, ULCER OVER DORSUM OF FOOT &RT CALF

GRADE II BEDSORE OF B/L GLUTEAL REGION S/P DISARTICULATION OF 5TH RT TOE &DEBRIDEMENT OF ULCER &BEDSORE UNDER SA

CANDIDIAL INTERTRIGO +FRICTIONAL DERMATITIS

S/P 9 SESSIONS OF HEMODIALYSIS DONE


Investigation:-

 RFT :

UREA : 93 mg/dl 50-17 mg/dl

CREATININE : 3.0 mg/dl 1.2-0.6 mg/dl

URIC ACID : 6.1 mg/dl 6-2.6 mg/dl

CALCIUM : 9.2 mg/dl 10.2-8.6 mg/dl

PHOSPHOROUS : 3.6 mg/dl 4.5-2.5 mg/dl 

SODIUM : 130 mEq/L145-136 mEq/L

POTASSIUM : 3.8 mEq/L5.1-3.5 mEq/L

CHLORIDE : 98 mEq/L98-107 mEq/L 

LIVER FUNCTION TEST (LFT)  :-

Total Bilurubin : 0.72 mg/dl 1-0 mg/dl

Direct Bilurubin : 0.16 mg/dl 0.2-0.0 mg/dl

SGOT(AST) : 40 IU/L 31-0 IU/L

SGPT(ALT) : 23 IU/L 34-0 IU/L

ALKALINE PHOSPHATE : 135 IU/L141-53 IU/L

TOTAL PROTEINS : 5.2 gm/dl8.3-6.4 gm/dl 

ALBUMIN : 2.9 gm/dl4.6-3.2 gm/dl 

A/G RATIO1.25 

Anti HCV Antibodies - RAPID    

Non Reactive HBsAg RAPID Negative 

COMPLETE URINE EXAMINATION (CUE) 15-11-2023 06:44:PM

COLOUR Pale yellow

  APPEARANCE  Clear  

REACTION Acidic

SP.GRAVITY1.010 

ALBUMIN+++SUGAR Nil 

BILE SALTS Nil 

BILE PIGMENTS Nil PUS CELLS4-5

EPITHELIAL CELLS3-4

RED BLOOD CELLS Nil CRYSTALS Nil CASTS Nil 

AMORPHOUS DEPOSITS Absent

OTHERS Nil 

ABG 16-11-2023 10:28:AM

PH7.13

PCO 266.7

PO241.2

HCO321.6

St.HCO318.1

BEB-7.3

BEecf-6.2

TCO248.8O2

 Sat69.1O2

 Count8.5

RFT 16-11-2023 11:56:AM 

UREA 117 mg/dl 50-17 mg/dl 

CREATININE4.4 mg/dl 1.2-0.6 mg/dl

 URIC ACID7.2 mg/dl 6-2.6 mg/dl

 CALCIUM9.5 mg/dl10.2-8.6 mg/dl

PHOSPHOROUS6.0 mg/dl4.5-2.5 mg/dl

SODIUM134 mEq/L145- 136 mEq/L

POTASSIUM4.3 mEq/L5.1-3.5 mEq/L

CHLORIDE97 mEq/L98-107 mEq/L

ABG 16-11-2023 12:43:PM

PH7.14

PCO259.4

PO231.3

HCO319.8

St.HCO316.9

BEB-8.6

BEecf-7.7

TCO244.7

O2 Sat51.2

O2 Count6.2

ABG 16-11-2023 04:33:PM

PH7.26

PCO246.9

PO254.7

HCO320.5

St.HCO319.5

BEB-5.7

BEecf-5.4

TCO244.5

O2 Sat 49.1

O2 Count11.1

ABG 16-11-2023 11:05:PM

PH7.18

PCO254.0

PO243.3

HCO319.7

St.HCO317.6

BEB-8.0

BEecf-7.2

TCO243.5

O2 Sat74.1

O2 Count9.9

ABG 16-11-2023 11:08:PM

PH7.19

PCO240.0

PO257.9

HCO314.7

St.HCO314.7

BEB-11.7

BEecf-12.0

TCO234.9

O2 Sat94.5

O2 Count3.0

RFT 16-11-2023 11:09:PM

UREA139 mg/dl50-17 mg/dl

CREATININE5.1 mg/dl1.2-0.6 mg/dl

URIC ACID7.9 mg/dl6-2.6 mg/dl

CALCIUM9.2 mg/dl10.2-8.6 mg/dl

PHOSPHOROUS5.7 mg/dl4.5-2.5 mg/dl

SODIUM132 mEq/L145-136 mEq/L

POTASSIUM4.2 mEq/L5.1-3.5 mEq/L

CHLORIDE102 mEq/L98-107 mEq/L

ABG 17-11-2023 12:09:PM

PH7.16

PCO266.1

PO258.0

HCO323.0

St.HCO318.3

BEB-7.3

BEecf-4.4

TCO247.1

O2 Sat83.5

O2 Count19.6

ABG 17-11-2023 08:06:PM

PH7.17

PCO243.5

PO280.4

HCO315.4

St.HCO315.1

BEB-11.4

BEecf-11.5

TCO236.1

O2 Sat100.1

O2 Count5.3

ABG 18-11-2023 01:42:AM

PH7.16

PCO263.7

PO259.6

HCO322.3

St.HCO319.3

BEB-6.0

BEecf-5.1

TCO249.6

O2 Sat87.0

O2 Count10.8

 LIVER FUNCTION TEST (LFT) 18-11-2023 01:42:AM

 Total Bilurubin1.48 mg/dl 1-0 mg/dl 

Direct Bilurubin0.30 mg/dl 0.2-0.0 mg/d

lSGOT(AST)144 IU/L 31-0 IU/

L SGPT(ALT)51 IU/L 34-0 IU/L 

ALKALINE PHOSPHATE380 IU/L 141-53 IU/L

 TOTAL PROTEINS5.1 gm/dl8.3-6.4 gm/dl

ALBUMIN2.4 gm/dl4.6-3.2 gm/dl

A/G RATIO0.88RFT 18- 11-2023 01:42:AM

UREA117 mg/dl 50-17 mg/dl

 CREATININE4.8 mg/dl 1.2-0.6 mg/dl

 URIC ACID6.7 mg/dl 6-2.6 mg/dl

 CALCIUM8.6 mg/dl10.2-8.6 mg/dl

PHOSPHOROUS5.4 mg/dl4.5-2.5 mg/d

lSODIUM132 mEq/L145- 136 mEq/

LPOTASSIUM3.6 mEq/L5.1-3.5 mEq/L

CHLORIDE94 mEq/L98-107 mEq/L

ABG 18-11-2023 10:26:AM:-

PH7.29

PCO251.5

PO2218

HCO324.1

St.HCO322.7BEB-2.1BEecf-1.5TCO251.5

O2 Sat98.3O2 Count13.9

ABG 19-11-2023 12:01:AM:-

PH7.26PCO254.2

PO29

6HCO324.0

St.HCO322.4

BEB-2.4

BEecf-2.0TCO252.7

O2 Sat98.0

O2 Count10.7

RFT 19-11-2023 12:01:AM

UREA83 mg/dl50-17 mg/dl

CREATININE4.0 mg/dl1.2-0.6 mg/d

lURIC ACID5.2 mg/dl6-2.6 mg/dl

CALCIUM8.5 mg/dl10.2-8.6 mg/dl

PHOSPHOROUS4.2 mg/dl4.5-2.5 mg/d

lSODIUM134 mEq/L145-136 mEq/L

POTASSIUM3.9 mEq/L5.1-3.5 mEq/L

CHLORIDE99 mEq/L98-107 mEq/L

ABG 19-11-2023 10:07:AM

PH7.23

PCO249.0

PO2173

HCO319.8

St.HCO318.7

BEB-7.0

BEecf-6.5TCO243.1

O2 Sat 97.4

O2 Count 13.1

ABG 19-11-2023 11:49:PM

PH7.28.

HCO320.9

BEB-4.2

BEecf-3.8

TCO246.8

O2 Sat98.0

O2 Count13.4

LIVER FUNCTION TEST (LFT) 19-11-2023 11:49:PM:-

Total Bilurubin3.60 mg/dl1-0 mg/dl

Direct Bilurubin2.96 mg/dl0.2-0.0 mg/dl

SGOT(AST)91 IU/L31-0 IU/L

SGPT(ALT)57 IU/L34-0 IU/L

ALKALINE PHOSPHATE127 IU/L141-53 IU/L

TOTAL PROTEINS5.1 gm/dl8.3-6.4 gm/d

lALBUMIN2.3 gm/dl4.6-3.2 gm/dl

A/G RATIO0.83RFT 19-11-2023 11:49:PM:-

UREA109 mg/dl50- 17 mg/dl

CREATININE2.6 mg/dl1.2-0.6 mg/d

lURIC ACID7.8 mg/dl6-2.6 mg/dl

CALCIUM10.0 mg/dl10.2-8.6 mg/d

lPHOSPHOROUS5.6 mg/dl4.5-2.5 mg/d

lSODIUM132 mEq/L145-136 mEq/L

POTASSIUM4.3 mEq/L5.1-3.5 mEq/L

CHLORIDE98 mEq/L98-107 mEq/L

ABG 21-11-2023 03:20:AM

PH7.24

PCO250.0

PO241.5

HCO321.1

St.HCO320.2

BEB-4.9

BEecf-5.0

TCO248.6

O2 Sat84.9O2 Count4.8

RFT 21-11-2023 03:20:AM

UREA96 mg/dl 50-17 mg/dl

 CREATININE3.8 mg/dl,1.2-0.6 mg/dl

 URIC ACID5.6 mg/dl 6-2.6 mg/dl

 CALCIUM10.0 mg/dl 10.2-8.6 mg/dl

 PHOSPHOROUS5.0 mg/dl4.5-2.5 mg/dl

SODIUM133 mEq/L145-136 mEq/L

POTASSIUM4.0 mEq/L5.1-3.5 mEq/L

CHLORIDE98 mEq/L98-107 mEq/L

 BLOOD FOR C/S ON 22/11/23 - REPORT: 

NO GROWTH AFTER 1 WEEK OF AEROBIC INCUBATION C/S OF DEBRIDED TISSUE FROM THE WOUND SITE

 REPORT ON 23/11/23: FEW DISINTEGRATED PUS CELLS, FEW GRAMPOSITIVE COCCI IN SINGLES, PAIRS SEEN, OCCASIONAL GRAM NEGATIVE BACILLI SEEN , OCC BUDDING YEAST CELLS SEEN. CANDIDA ALBICANS ISOLATED. 

URINE FOR C/S ON 17/11/23 REPORT: 3-4 PUS CELLS SEEN, INSIGNIFICANT GROWTH.

 Treatment Given:-

O2 INHALATION TO MAINTAIN SPO2 >95% BIPAP FOR 18 HRS

INJ MOXIFLOXACIN 400MG IV OD , 8AM INJ METROGYL 500MG IV 8TH HRLY 

INJ LINEZOLID 600MG IV 12TH HRLY 

INJ MEROPENEM 1GM IV 12TH HRLY 

INJ HYDROCORTISONE 100MG IV PRIOR TO DIALYSIS 

INJ PANTOP 40 MG IV BBF

INJ LASIX 40MG IV BD 

INJ PCM 1G IV IF TEMP >101F 

TAB PCM 650MG PO 8TH HRLY 

TAB ATORVASTATIN 40MG RT/OD 

TAB ACEBROPHYLLINE 100MG RT/12TH HRLY 

TAB NODOSIS 500MGRT 8TH HRLY 

TAB SHELCAL CT RT OD

TAB OROFER XT RT OD 

INJ HUMAN ACTRAPID INSULIN SC/PREMEAL 12U ABSORB DUSTING POWDER LA BD

COTRIMAZOLE 1% CREAM LA BD 

RT LOWER LIMB ELEVATION REGULAR POSITION CHANGING 2ND HRLY ALPHA BED 

TAB AMLONG 5MG PO OD 

TAB ECOSPRIN 75MG PO OD 

TAB CLOPIDOGREL 75MG PO OD.

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