general medicine case presentation

A 65 year old male resident of Mallepally ,farmer by occupation presented to the causality with loss of consciousness (For a period of 15min) associated with sweating.


HISTORY OF PRESENT ILLNESS: 

Patient was apparently normal until 15 days back. Then he had a thorn prick injury to the right foot for which he has taken treatment from a local RMP. 

The local RMP performed incision and drainage after which the swelling increased over right lower limb foot with boils over the ankle  

He then visited another hospital where he was told to have increased creatinine level (0.7mg/dl) 

He then was referred to a higher centre 

The patient was then taken to the hospital and haemodialysis was done and planned for a debridement  

Debridement was done and was discharged  

After which he has experienced a sudden loss of consciousness associated with sweating and was brought here. 

No h/o fever, sob, palpitations, chest pain. 


PAST HISTORY: 

k/c/o diabetes Mellitus type 2  since 10 years 

N/k/c/o HTN, TB, epilepsy, thyroid disorder, bronchial Asthma.


TREATMENT HISTORY : 

Metformin 500mg 


PERSONAL HISTORY : 

sleep : inadequate 

Bowel and bladder : regular 

Appetite : normal 

Addictions: none 

Allergies : none 


GENERAL EXAMINATION: 

no signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy, Oedema of foot.

Vitals: 

Temperature: afebrile 

Pulse rate : 112

Respiratory rate : 13 cpm

BP: 140/80 mm/hg

GRBS: 108mg% 

SYSTEMIC EXAMINATION : 

CVS: 
Thrills: no 
Cardiac sounds: s1,s2 + 
Cardiac murmurs : no 

RESPIRATORY SYSTEM: 
Dyspnoea: no 
Wheeze: no 
Position of trachea: central 
Breath sounds: vesicular 

ABDOMEN: 
Shape of abdomen : scaphoid 
Tenderness: not 
Palpable mass: no 
Hernial orifice:Normal 
Free fluid: no 
Bruits: no 
Liver: not palpable 
Spleen: not palpable 
Bowel sounds: yes 

CENTRAL NERVOUS SYSTEM: 
1. Level conscience: conscious 
2. Speech: normal 
3.glassgow scale:15/15


INVESTIGATIONS : 

1. C-reactive protein : 


2. ESR: 


3. Bleeding and clotting time : 

4. Blood sugar- fasting : 

 Lipid profile : 

6. RFT : 



7 serum iron: 


 
8. Blood lactate : 


9.serum magnesium : 

10. Blood sugar -fasting : 


11. Blood group and RH type: 


12. CBP: 



Hemogram: 

 

14. CUE : 



15. Anti HCV antibodies : 


16.


17.HIV 1/2 rapid test : 


18. Ultrasound: 


19. ECG: 



PROVISIONAL DIAGNOSIS: 

AKI secondary to sepsis 
With right lower limb cellulitis 
With k/c/o diabetes since 10 years 
With 4 sessions of hemodialysis done  


TREATMENT : 
  1. INJ PIPTAZ 2.25G IV/BD
  2. INJ METROGYL 500MG IV/TID
  3. INJ HAI S/C TID
  4. INJ LASIX 40MG IV/BD
  5. TAB ALDACTONE 25MG PO/BD






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