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A 54 year old male patient presented to casualty with the cheif complaint of left lower limb swelling since five days
Complains of shortness of breath grade 2
History of present illness:
Patient was asymptomatic 5 days back then he had injury to left leg followed by itching of leg and develoed left lower limb swelling associated with sob grade 2
In 2016 patient has chronic encephalopathy followed by 4 sessions of dialysis was done .and discharged and not on any medication after discharge.
Past history:
No Diabetes mellitus
No HTN
No EPILEPSY
No asthama
No TB
Personal history :
Diet:mixed diet
Sleep: adequate
Apetite :normal
Bowel n bladder movements :regular
Micturition :normal
Habits: alcoholic and smoking
Apetite :normal
Bowel n bladder movements :regular
Micturition normal
Habits: alcoholic and smoking
Drug history:
Patient was not allergic to any known drugs
Family history: there is no history of similar complaints of family members
General examination:
Patient is conscious coherent co-operative he is well oriented to time place and person
Built: moderately built and well nourished
Patient is pallor ,pedal edema is present
No cyanosis
No clubbing
No lymphadenopathy
No malnutrition
Vitals:
Temperature: 98.5F
Pulse rate:70/min
Respiratory rate:18/min
Bp:110/80
Spo2:98%
Systemic examination:
Cvs:
S1 S2 heard
No cardiac sounds heard
No thrills
Respiratory system:
No dysopnea
No wheezing
Position of trachea central
Breath sounds : vesicular
Abdomen;
Inspection: shape of the abdomen scaphoid
No abdomenal tenderness
No palpable masses
No hernial mass
No free fluid
No bruit
Bowel sounds yes
Central nervous system:
Patient is concious coherent and cooperative with time and place
Speech is normal
Cranial motor and sensory system normal
Provisional diagnosis:
Acute kidney injury with lower limb
cellulitis
Investigations:
Treatment:
1.injection meropenem 500 mg iv of
2.injection pan 40 mg po OD
3.inj. zofer 4 mg iv sos
4.neomol 1 GM iv
5. Tab . Ultracot po QID
6 .tab.pcm 650 mg iv sos
7.tab Lasix 40 mg po OD
8.tab mvt po od
9 .Tab chymerol forte po tid
10.tab vit c 500 mg po od
11.left lower limb elevation
12.Daily dressing for cellulitis
13.monitor vitals Bp pr Rr intervals.
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