Case history-8
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54 years old male patient came with chief complaints of shortness of breath and left lower limb swelling since 5 days .
HISTORY OF PRESENT ILLNESS:-
Patient was apparently asymptomatic 5 days back and then he had a injury to his left leg followed by itching in the leg and developed left lower limb swelling associated with shortness of breath ( grade II- III) according to NYHA classification.
No history of chest pain/palpitations.
No history of chronic cough/hemoptysis
In 2016 patient visitted to the hospital due to pedal edema where patient had Ischemic encephalopathy followed by 4 sessions of dialysis was done and discharged not as any medications after that.
PAST HISTORY:-
Patient is not a known case of DM, asthma, epilepsy hypertension.
PERSONAL HISTORY:
Diet-mixed
Appetite-decreased
Bowel and bladder movements-regular
Patient used to consume alcohol daily 5 years back and ,stopped 5 years back and recently he consumed 100 ml of alcohol
GENERAL EXAMINATION:
Patient is conscious, coherent, cooperative .
Pallor +
No icterus,cyanosis,clubbing,lymphadenopathy.
Left lower limb- Raw area of size 10x8 cms on anterio lateral aspect of left lower limb
Multiple blebs present all over the limbs
Pitting edema +
Right lower limb-
Pitting edema+
CLINICAL IMAGE'S
Date-06/12/2021
INVESTIGATIONS:
VITALS:
PR-98 bpm
RR-29cpm
BP-130/90 mm Hg
SpO2-98% @ RA
SYSTEMIC EXAMINATION:-
CVS-s1s2+
RS- BAE+
P/A- soft,non tender,BS+
PROVISIONAL DIAGNOSIS:-
CKD with left lower limb cellulitis
TREATMENT:-
Ivf Ns, RL urine output+30ml/hr
Tab lasix 40 mg po BD
Inj meropenum 500 mg/IV/BD
Inj PAN 40 mg/po/of
Inj zofer 4mg/IV/sos
Tab mvt po od
Tab vit c po/od
Left lower limb elevation
Daily dressings for LL cellulitis
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