74 year old male patient came to OPD with swelling in left lower leg



E LOG GENERAL MEDICINE.


Hi, I am Anupreethi Reddy, 6th Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.


This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING.

 * This is an ongoing case. I am in the process of updating and editing this ELOG as and when required.


                                   CASE SHEET.                                           


CHIEF COMPLAINTS AND DURATION


A 74 year old male patient came to opd with the chief complaints of swelling in left lower leg on Thursday afternoon.


HISTORY OF PRESENT ILLNESS 


Patient was apparently asymptomatic  5 days ago then he developed swelling on his left lower leg progressive in nature, aggravated on walking, relieved on taking rest and on elevation of leg.  


HISTORY OF PAST ILLNESS 


In 1987 he had a major accident where his right knee and hip was fractured for which a rod was placed by operation.

K/C/O HTN and DM since 15 years.  Patient had a burn on his right leg which was not relieved on self medication so he we t to the hospital. On investigations he was diagnosed with HTN and  DM. 

Joint pains since  5 years


PERSONAL HISTORY 

Patient is a retired RTC  worker by occupation.   

Bowel movement is regular.

Micturition is normal.

No history of Allergy.    

No addictions.


FAMILY HISTORY 

 Mother was a known case of HTN and DM. 



PHYSICAL EXAMINATION.

A. General Examination 

No Pallor

No icterus

No cyanosis

No clubbing of fingers

No lymphadenopathy

No malnutrition 

No clubbing of fingers

No dehydration

No pedal Oedema 

Temperature: 98.6 F

Pulse: 88/ min

Blood pressure: 110/70c







LOCAL EXAMINATION

On Inspection, left lower leg has bullae with serous discharge.

On palpation, local rise of temperature and tenderness are noted are noted.

LAB DIAGNOSIS




DIFFERENTIAL DIAGNOSIS

cellulitis on left lower leg


TREATMENT


IVF NS @75ml/hr

Inj PIPTAZ 2.25gram IV/BD

Inj CLINDAMYCIN 600mg IV/BD

Inj PAN 40mg IV/ OD

Inj HAI S/C TID before meals

Inj NEOMAL 1gm IV/SOS

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