45/F with swelling in the left leg and foot

  This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs .This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

45 year old female has come to opd with chief complaints of swelling of the left leg and foot since 1 week 

History of presenting illness :

Patient was apparently asymptomatic 1 week back then she developed swelling in the left leg which was insidious in onset and associated with erythema. No aggravating or relieving factors  

It is associated with pain which is of dragging type.

H/o trauma + ( pressure sore manipulated with a blade ) 

No h/o fever, constipation, pain abdomen 

H/o vomiting one day ago. 6 episodes, non bilious, non projectile, non blood stained and food as content 

Past history :

No h/o similar complaints in the past 

K/c/o DM since 6 years and is on Tab. Volgibase 0.2 mg , glimiperide 1 mg and metformin 500 mg

N/k/C/o HTN, epilepsy, asthma, CAD, thyroid disorders 

Personal history :

Sleep : adequate 

Diet : mixed 

Appetite : normal 

Bowel and bladder : regular 

Addictions : none 

General examination:

Pt is c/c/c 

No pallor , icterus , cyanosis, clubbing, lympadenopathy, edema 

Vitals : 

PR: 86 bpm

RR: 18cpm

BP: 160/100 mmHg

GRBS : 187 mg/dl 

Systemic examination : 

CVS :  S1 s2 heard no murmurs

RS : BAE NVBS heard. B/L crepts + in mammary area, axillary area, infrascapular area and infra axillary area

P/A : soft non tender 

No free fluid.

CNS : No FND

Investigations : 

Predialysis : 

3/7/23 

Post dialysis : 

4/7/23

ECG : 

Ultrasonography :

Chest X-Ray: 

Treatment :

 INTERMITTENT CPAP

IV FLUIDS NS 

INJ METROGYL 500 Mg. IV/TID

INJ TAXIM 1 g IV/BD 

INJ PAN 40 Mg IV/OD

INJ LABETALOL 100 Mg PO/BD

INJ. ZOFER 4 Mg IV/OD

TAB NICARDIA 10 Mg PO/QID

TAB ARKAMINE 0.1 mg PO/OD

SYP LACTULOSE 30 ml PO/HS

INJ HAI S/C TID 

1st Dialysis was done on 03/07/23 

Soap notes  

04/07/2023

ICU bed 1

Dr. Krishna Chaitanya 

Dr. Pavan 

Dr. Navya 

Dr. Gouri 

S:  

- anasarca +

-no fever spikes

-Stools not passed 

-slight pain over the left foot +

O:

Pt is conscious, coherent, cooperative. 

BP: 160/100 mmHg

PR: 86 bpm

RR: 16 cpm.                             

Spo2: 99% 

CVS: S1 s2 heard , no murmurs                                         RS: B/L air entry present. B/L crepts + in mammary area, axillary area, infra axillary area and infra scapular area. 

P/A: soft non tender 

CNS: no focal neurological deficit 

                                

 Local examination : 

Debridement done until fresh bleeding borders achieved and necrotic patch removed and ASD done under LA

A:

CHRONIC KIDNEY DISEASE ASSOCIATED WITH HYPERTENSIVE CRISIS WITH LEFT LOWER LIMB CELLULITIS WITH TYPE 2 DM SINCE 6 YEARS DIABETIC NEPHROPATHY 

P:

INTERMITTENT CPAP

IV FLUIDS NS 

INJ METROGYL 500 Mg. IV/TID

INJ TAXIM 1 g IV/BD 

INJ PAN 40 Mg IV/OD

INJ LABETALOL 100 Mg PO/BD

INJ. ZOFER 4 Mg IV/OD

TAB NICARDIA 10 Mg PO/QID

TAB ARKAMINE 0.1 mg PO/OD

SYP LACTULOSE 30 ml PO/HS

INJ HAI S/C TID 

1st Dialysis was done on 03/07/23 

Fever chart :