80/F with pain and swelling in the left knee with hypokalemia, hypotension and recurrent hypoglycaemia

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80 year old female has come to casualty on 11/07/23 with c/o :

Pain in the left knee since 6 days

Swelling in the left knee since 6 days

Fever since since 6 days

History of presenting illness :

Patient was apparently alright before 5/7/23, then she developed high grade fever which is continuous, associated with chills for which she got treated by a local doctor. 

On 5/7/23 night, she developed pain and swelling in the left knee which was pricking type, aggravated on movement and relieved on taking rest. 

H/o similar complaints in the past for which fasciotomy was done. 

Fasciotomy was done to the right side 5 months ago from left mid thigh to left anterior aspect of ankle 

Fasciotomy was done to the left knee 4 months ago. 

Knee aspiration was done on 07/07/23, 50 ml of serosanginous fluid was aspirated  

Distal pulses +

Sensation present 

Tenderness absent 

No local rise of temperature 

Incision and drainage for left knee synovitis with left lower limb cellulitis was done on 11/07/23

She was referred to general medicine i/v/o :

Hypokalemia 

Hypoglycaemia 

Hypotension 

H/o vomiting on 21/07/23. One episode, non bilious, non projectile and food as content 

Nausea +

Reduced appetite +

No h/o abdominal pain, abdominal distension, reduced urine output 

No h/o shortness of breath , chest pain 

 

Daily routine : 

The patient has a sedentary lifestyle. 

She usually wakes up by 6 AM in the morning and has her breakfast by 8 AM. She has a cup of tea with biscuits and a chocolate  

She watches TV for sometime and rests  

She has lunch at around 1 pm. She usually has a bowl of rice with curry (preferably vegetarian) and she drinks a glass of buttermilk 

In the evening, she has another cup of tea. 

She has a bowl of rice and curry for dinner by 8 pm and goes to bed by 10 pm 

Past history :

K/c/o DM since 4 years and is on medication (Tab Metformin 500 mg PO/OD) 

K/C/O HTN since 4 months and is on medication

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

Personal history :

Sleep : adequate 

Diet : mixed 

Appetite : reduced

Bowel and bladder : regular 

Addictions :  smoking - sutta since the age of 14. (4-5 per day) Stopped smoking 2 years back. 

she consumes toddy, occasionally. 

General examination:

Pt is conscious, coherent and irritable 

No pallor , icterus , cyanosis, clubbing, lympadenopathy

Pedal edema + (pitting type)

Vitals : 

PR: 118 bpm

RR: 18 cpm

BP: 110/70 mmHg

GRBS : 96 mg/dl 

Systemic examination : 

CVS :  S1 S2 heard no murmurs

RS : BAE NVBS heard.

P/A : soft non tender 

No free fluid.

CNS : No FND

Local Examination : 

Left Lower Limb -

2 tattoo marks on lateral aspect of the left knee 

Shiny skin from left mid thigh to anterior aspect of the ankle

Diffuse swelling + extending from mid thigh to left ankle

2 blisters + measuring about 2x3 cm on left lateral aspect of knee and 2x5 cm on anterior aspect of midline 

Crepitus absent 

Diffuse tenderness + 

Patella tap +

Flucation test +

Local rise of temperature +

Movement - painful and restricted 

Sensation - intact 

Distal pulses +

Right Lower Limb :

5 cm scar line present on the medical aspect of left mid line of thigh

Swelling absent 

Tenderness absent 

Crepitus absent

No local rise of temperature 

 

Investigations :

ABG: 

Culture report :

ECG :

20/07/23 -

X ray chest :

19/07/23 -

Ultrasonography :

   2D Echo :

   TREATMENT :

IV FLUIDS NS and DNS @ UO + 30 ml/ hr

RT FEEDS - 100 ml water 2nd hourly 

                      100 ml milk 4th hourly 

INJ PIPTAZ 2.25 mg IV/TID

INJ ZOFER 40 mg IV/TID

TAB OROFER-XT RT/OD

TAB MVT RT/OD

TAB LIMCEE 500 mg RT/BD

TAB CILASTAZOL 100 mg RT/BD

TAB 40 mg RT/OD

TAB ULTRACET RT/OD

TAB DOLO 650 mg RT/SOS

INJ KCL 1 AMP  IN 500 ml of NS OVER 4-6 hours/STAT 

INJ OPTINEURON 1 AMP in 500 ml NS IV/OD

TAB NODOSIS 500 mg PO/BD

INJ SODIUM BICARBONATE 50 mg- slow over 20 minutes

INJ LASIX 40 mg IV/STAT