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Name : Supriya .K ( Intern )
Roll Number : 63
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.
A 60YRS OLD MALE PATIENT from venugonda came to the general surgery OPD with
Chief complaints of: swelling and blackish discoluration of left foot to the 2nd toe since 20 days
(he was referred to general medicine for (HIGH BLOOD SUGAR LEVELS ) - After RAYS AMPUTATION done
HISTORY OF PRESENTING ILLNESS :
Patient was apparently asymptomatic 20 days ago and then he developed swelling over left 2nd toe followed by which ulceration occurred which was sudden in onset gradually progressive.
Ulcer is associated with pain ,which is on and off and dull aching type . No aggravating factors but relieved with medication .
He also developed Blackish discolration of left 2nd toe which was sudden in onset and progressive to involve whole 2nd toe .
(Referred to the general medicine department for high blood sugar levels )
NO H/O fever, trauma, discharge from wound, vomiting, abdominal pain, breathlessness
PT UNDERWENT RAYS AMPUTATION:
PAST HISTORY :
H/O Similar complaints in the past over the right foot and dorsum of left foot.
Patient is a K/C/O Diabetes mellitus since 3 years {under medication metformin 400 mg}.
K/C/O Hypertension since 1 year.[unknown medication]
PERSONAL HISTORY :
Appetite: Normal
Diet: Mixed
sleep: Adequate
Bowel and bladder movements: Regular
Addictions: Occasionally alcoholic
Allergic : No allergies
GENERAL EXAMINATION
Patient is conscious, coherent, cooperative. Moderately Built , Moderately Nourished .
Pallor - absent
Icterus - absent
Clubbing - absent
Cyanosis - absent
Lymphadenopathy - absent
Edema - absent
VITALS:
Temperature: Afebrile
BP: 140/90 mmhg
pulse rate: 90bpm
Respiratory rate: 14 cpm
GRBS CHARTING : (17/12/22) :
8AM : 156 mg/dl - 8U HAI ,6U NPH
10AM : 356 mg /dl
2PM : 195 mg/dl -8U HAI
4PM : 252 mg /dl
8PM : 150 mg/dl - 6U HAI ,6U NPH
10PM : 118 mg/dl
2AM : 76 mg /dl
4AM : 169 mg/dl
8AM : 290 mg/dl - 10U HAI ,8U NPH
17/12/22 (8AM ) TO 18/12/22 (8AM)
18/12/22 (8AM) to 19/12/22 (8AM) :
19/12/22 (8AM ) to 20 /12/22 (8AM) :
SYSTEMIC EXAMINATION :
CVS : S1 S2 Heard
RS : BAE +
CNS : HMF +
On Fundoscopy ; No significant changes noted - Diabetic Retinopathy absent ( but advised strict diabetic diet )
Motor Examination:
RT LT
Tone : UL - N N
LL - N N
Power : UL -4/5 4/5
LL- 4/5 4/5
Reflexes : biceps: 2+ 2+
Triceps : 2+ 2+
Knee: 2+ 2+
Ankle : 1+ 1+
Supinator : 1+ 1+
Vibrations : great Toe - 4.22 secs 5.94 secs
Medial malleolus -4.14 secs 4.86secs
Tibia shaft - 5 secs 6secs
Joint Position : 10% 10%
P/A : Soft and Non tender
INVESTIGATIONS:
USG ABDOMEN:
Hemangioma in the RT lobe of liver
Raised echogenesity of bilateral kidneys
BACTERIAL CULTURE AND SENSITIVITY:
Nature of specimen : Pus Swab
Culture report : Kblesiella Pneumonia species isolated
SUGAR PROFILE:
FBS - 440 mg/dl
PLBS - 386 mg/dl
HbA1c - 7.8 %
Urine for ketone bodies: Negative
2D ECHO :
Arterial Doppler of B/ L lower limbs :
Bilateral Arm Muscle Mass and Visceral Fat :
PROVISIONAL DIAGNOSIS:
Dry Gangrene of left 2nd toe S/P Rays amputation of 2nd toe
klebsiella pneumonia detected with in swab c/s resistant to amoxyclav and cotrimoxazole
AKI on ? CKD
( k/c/o HTN since 1 year and DM 2 since 3 years )
MANAGEMENT:
Inj Piptaz 2.25gms IV / QID - Day 1
inj HAI s/c according to GRBS
T. lasix 20mg PO/BD
T. Dolo 650mg Po/Sos
T. Chymerol forte Po/TID
T. Vit-C PO/OD
GRBS 7 Point profile
Vitals monitoring 4th hrly
SOAP NOTES:
AMC
Day -4
Bed -4
unit -3
S
Stool passed and no fever spikes
O
Pt is conscious ,coherent , cooperative
Temp: afebrile
BP: 130/80mmHg
PR : 80bpm
RR :18 cpm
GRBS :156 mg/dl
CVS : S1 S2 +
RS : BAE +
CNS :NAD ,HMF+
P/A : Soft and nontender
A
Dry Gangrene of left 2nd toe S/P Rays amputation of 2nd toe
Type 2 DM with uncontrolled Sugars
AKI on ? CKD
( k/c/o HTN since 1 year and DM 2 since 3 years )
P
Inj Augmentin 1.2gms IV/BD
Inj HAI s/c according to GRBS
T. Pan 40mg PO/OD
T. Dolo 650mg Po/SOS.
T. Chymerol forte Po/TID.
T. Vit-C PO/OD
GRBS 7 Point profile
Vitals monitoring 6th hrly.
AMC
Day -5
Bed -4
unit -3
S
Stool passed and no fever spikes
O
Pt is conscious ,coherent , cooperative
Temp: afebrile
BP: 130/80mmHg
PR : 84bpm
RR :18 cpm
GRBS Charting :
8AM : 156 mg/dl - 8U HAI ,6U NPH
10AM : 356 mg /dl
2PM : 195 mg/dl -8U HAI
4PM : 252 mg /dl
8PM : 150 mg/dl - 6U HAI ,6U NPH
10PM : 118 mg/dl
2AM : 76 mg /dl
4AM : 169 mg/dl
8AM : 290 mg/dl - 10U HAI ,8U NPH
creatinine clearance : 31ml /min
I/O : 1100/ 800 ml
CVS : S1 S2 +
RS : BAE +
CNS :NAD ,HMF+
P/A : Soft and nontender
A
Dry Gangrene of left 2nd toe S/P Rays amputation of 2nd toe
klebsiella pneumonia detected with in swab c/s resistant to amoxyclav and cotrimoxazole
AKI on ? CKD
( k/c/o HTN since 1 year and DM 2 since 3 years )
P
Inj Piptaz 2.25gms IV / QID - Day 1
inj HAI s/c according to GRBS
T. lasix 20mg PO/BD
T. Dolo 650mg Po/Sos
T. Chymerol forte Po/TID
T. Vit-C PO/OD
GRBS 7 Point profile
Vitals monitoring 4th hrly
AMC
Day -6
Bed -4
unit -3
S
Stool passed and no fever spikes
O
Pt is conscious ,coherent , cooperative
Temp: afebrile
BP: 100/70 mmHg
PR : 76bpm
RR :18 cpm
GRBS Charting :
8AM : 295mg/dl - 10U HAI ,8U NPH
10 AM : 290 mg/dl
2PM : 175 mg/dl - 10U HAI
4PM : 268 mg /dl
8PM : 83 mg/dl - 4U HAI ,4U NPH
12AM : 295 mg/dl
2AM : 311 mg/dl
8AM : 133 mg/dl - 10U HAI , 6U NPH
creatinine clearance : 32 ml /min
I/O : 900/850 ml
CVS : S1 S2 +
RS : BAE +
CNS :NAD ,HMF+
P/A : Soft and nontender
A
Dry Gangrene of left 2nd toe S/P Rays amputation of 2nd toe
klebsiella pneumonia detected with in swab c/s resistant to amoxyclav and cotrimoxazole
AKI on ? CKD
( k/c/o HTN since 1 year and DM 2 since 3 years )
P
IV fluids 1. NS @ 50ml /hr
Inj Piptaz 2.25gms IV / QID - Day 2
inj HAI s/c according to GRBS
T. lasix 20mg PO/BD
T. Dolo 650mg PO/SOS
T. Chymerol forte PO/TID
T. Vit-C PO/OD
GRBS 7 Point profile
Vitals monitoring 4th hrly
AMC
Day -7
Bed -4
unit -3
S
Stool passed and no fever spikes
O
Pt is conscious ,coherent , cooperative
Temp: afebrile
BP: 110/70 mmHg
PR : 76bpm
RR :18 cpm
Creatinine clearance : 43ml /min
GRBS Charting :
8AM : 133mg/dl - 10U HAI , 8U NPH
10AM : 206 mg/dl
2PM : 122 mg/dl - 10U HAI
4PM : 314 mg /dl
8PM : 135mg/dl
2AM : 85mg/dl
8AM : 159 mg/dl - 10U HAI
CVS : S1 S2 +
RS : BAE +
CNS :NAD ,HMF+
P/A : Soft and nontender
A
Dry Gangrene of left 2nd toe S/P Rays amputation of 2nd toe
klebsiella pneumonia isolated in swab c/s resistant to amoxyclav and cotrimoxazole
AKI on ? CKD
( k/c/o HTN since 1 year and DM 2 since 3 years )
P
IV fluids 1. NS @ 50ml /hr
Inj Piptaz 2.25gms IV / QID - Day 3
Tab.pan 40 mg po/ OD
T. lasix 20mg PO/BD
Tab.Nicardia 10 mg po/BD
T. Chymerol forte PO/TID
T. Vit-C PO/OD
inj.HAI,NPH s.c/ TID
(HAI- 10 U 10 u. 8u
NPH - 6 U. 4u)
GRBS 7 Pint profile
Vitals monitoring 4th hrly
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