A CASE OF AKI ON CKD STAGE V WITH CELLULITIS PRESENTED IN SUMMER 2023
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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 a diagnosis and providing treatment best to our skills and wisdom.
A 75yr old patient, farmer by profession , presented to the casualty with complaints of painful lesions and swelling over left leg.
Date of Admission: 31/05/23
CHIEF COMPLAINTS
➤ Painful lesions and swelling over left leg since 4 days .
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 4 days back . Then he applied zandu balm over left limb and developed swelling which was gradually progressive.
He had h/o fever since 4 days , not associated with chills and rigor
He had a h/o similar complaints 1 yr back followed by trauma .
HISTORY OF PAST ILLNESS
➤Not a K/c/o diabetes, hypertension, asthma , epilepsy tuberculosis , CAD
➤No surgical history
➤No history of Blood transfusions.
PERSONAL HISTORY
➤Occupation: Farmer.
➤Patient is married .
➤Patient takes mixed diet and has a normal appetite.
➤Sleep : Regular
➤Bowel and bladder movements are normal.
➤No known allergies .
➤ Addictions - Alcohol : 90ml at night .
Bidi : 3 times
FAMILY HISTORY
Not significant .
GENERAL EXAMINATION
➤Pallor :Not seen
➤Icterus : Not seen
➤Cyanosis : Not seen
➤Clubbing : Not seen
➤Lymphadenopathy : Not seen
➤Edema : Seen - pitting type .
VITALS
➤Temperature : 98.3℉
➤PR : 90 beats per minute
➤BP : 100/70 mm of Hg
➤RR : 20 cycles per minute
➤SpO2 : 96% in room air
➤Blood Sugar (random) : 97mg/dl
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM EXAMINATION
➤s1 and s2 heard
➤Thrills absent.,
➤No cardiac murmurs
RESPIRATORY SYSTEM
➤Normal vesicular breath sounds heard.
➤Bilateral air entry present
➤Trachea is in midline.
ABDOMINAL EXAMINATION
INSPECTION
➤Shape - Scaphoid
➤Equal movements in all
the quadrants.
➤No visible pulsation, dilated veins and localized swellings.
PALPATION
➤Liver , spleen not palpable.
➤No tenderness
CENTRAL NERVOUS SYSTEM EXAMINATION
➤Conscious and coherent
➤Speech : Normal
➤No signs of meningeal irritation
Neck stiffness: no
Kernig's sign : no
LOWER LIMB EXAMINATION
INSPECTION
➤ Skin over the lower limb is tense with blebs .
➤ Blackish discoloration over the posterior aspect of left thigh
➤ Single erythematous patch over the lateral aspect of left thigh
➤ Bullae noted over the dorsum of left foot and leg .
PALPATION
➤ Tenderness present upto left thigh.
➤ Local rise of temperature present
➤ Fluctuation is present .
➤ Skin is tense .
➤ Pitting type of edema present over Rt. lower limb till knee joint .
PROVISIONAL DIAGNOSIS : AKI on CKD stage V with lt. lower limb cellulitis with sinus arrythmia and thrombocytopenia.
INVESTIGATIONS
1) BACTERIAL CULTURE AND SENSITIVITY REPORT
Dt : 08/06/23
Dt : 06/06/23
Dt : 03/06/23
2). USG
Dt : 06/06/2023
3) ECG
Dt : 31/05/23
Dt: 06/06/23
4) 2D ECHO
Dt : 01/06/23
5) GRBS
Dt - 31/05/23
6) BLOOD UREA
Dt : 31/05/23
7) SERUM CREATININE
Dt : 31/05/23
8) SERUM POTASSIUM
Dt : 31/05/23
9) SERUM SODIUM
Dt : 31/05/23
10) LFT
Dt : 31/05/23
11) SERUM PHOSPHORUS
Dt: 31/05/23
12) SERUM CALCIUM
Dt: 31/05/23
13) SERUM CHLORIDE
Dt : 31/05/23
14) INTAKE AND OUTPUT CHARTS
Dt : 02/06/23
Dt : 04/06/23
15) FEVER CHART
TREATMENT
1. Normal diet
2. Inj. Monocef 1gm IV BD
3. Inj. Metrogyl 400mg IV TID
4. Inj. Pantop 40mg IV OD
5. Tab. Dolo 650 mg PO BD
6. Tab . Mut PO OD
7. Tab . Limcee PO OD
8. Foot end elevation .
