General medicine case-09
A 54 year old male patient,farmer by occupation presented to the opd with the chief complaint of left lower limb swelling and sob since 5 days.
History of present illness:
Patient was apparently asymptomatic 5 days back then he had then he had infection to his left leg which was followed by itching and he developed swelling of left lower limb which followed by pain.
6 months back he noticed same type of infection and swelling on right lower limb for which he considered a local doctor and was cured by medication.
In 2016,he had attack of sob and pedal edema for which he went to hospital and was told that creatinine has increased and did dialysis for 4 times until creatine becomes normal.
Past history:
Patient is known case of hypertension. Not a known case of diabetes mellitus,bronchial asthma,epilepsy & tuberculosis.No history of any surgeries.
Personal history:
Mixed diet
Bowel & bladder - Normal
Sleep adequate
H/o smoking,alcohol consumption
Loss of appetite
Family history:
No family history
General Examination:
The patient is conscious,coherent and cooperative.He was well oriented to time ,place and person.
No Pallor
No Icterus
No Cyanosis
No Lymphadenopathy
No Pedal Edema
Temperature-98.5degree F
Pulse rate-99 beats/min
Respiratory Rate- 18/min
Blood pressure- 110/80
SpO2 - 99% at room temperature
Systemic examination:
CVS : No thrills
S1 S2 +
RS- No dyspneoa,No wheeze
Breath sounds-Vesicular
per abdomen- soft,non tender
CNS- Conscious,Speech normal.
Provisional Diagnosis:
AKI secondary to left lower limb cellulitis.
Investigations :
Treatment:-
IVF
Inj Meropenam 500mg
Inj pan 40mg
Inj zofer 4mg/Iv
Inj Neomol 1mg/Iv
Tab ultracet
Tab lasix 40mg
Tab PCM 650 mg
Tab chemorol forte
Tab MVT
Vit c 500mg
Follow up:-
11/12/21
When I went for follow up he was having right lowerlimb swelling also left lower limb swelling was also there but pain was subsided little.
