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

Comments

Post a Comment

Popular posts from this blog

53 year old female came with Dizziness

Image
  Chief complaints: altered sensorium,difficulty in walking ,loss of speech,weakness of right upper limb and right lower limb HOP1: Patient is diabetic since 11 years and hypertensive since 1 year  During recent regular health checkup Blood Glucose level was 350 mmol/L and blood pressure was 280mm Hg. Later that day she developed giddiness and was unable to walk properly so was brought to the hospital. Negative History : No History of Headache,Fever,Vomiting ,Chest Pain,Palpitations and Shortness of Breath. Past history:  She was diagnosed with diabetes 11 years ago when she went to a doctor in her locality due to frequent urination. High Bp was noticed during regular blood glucose level checkup.  On medication(diabetic and anti hypertensive drugs) Treatment History : For Diabetes -Dapaglifozin 10mg                              -Metformin 500mg For Hypertension : Telma 40mg  Cilindipine 10mg Metoprolol 50mg Personal History: Vegetarian Appetite Normal Bowel And Bladder-Regular   Sleep
Read more

80 year old male with cough and difficulty in breathing since 2 years

Image
  Hi, this is Anupreethi Reddy, a medical student currently studying in KIMS Narketpally. This page is a compilation of cases taken up during my medical school years, with an intent to correlate theoretical concepts of medicine to practical aspects of it. These E-logs have been created after taking consent from the patient and the patient's advocate. So welcome, and I encourage you to immerse yourselves into these interesting cases. NOTE: THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT. An 80 year old male patient, farmer by occupation, resident of Nalgonda came to the hospital with  CHIEF COMPLAINTS  of cough and difficulty in breathing since 2 years, whic
Read more

35 year old female with fever, cough and joint pains

Image
  Note: This is an online E Log book recorded by Anupreethi to discuss and comprehend our patient's     de-identified health data shared, AFTER taking his/her/guardian's signed informed consent. Chief complaints: Fever since 2 weeks, dry cough since 2 weeks, joint pains since 2 weeks HOP1: 35 yr old female patient housewife by occupation brought to casualilty with fever, cough and joint pains(knee joint, ankle joint, metacarpophalangeal joint . She had high grade, continuous fever    associated with chills and rigors. She had similar fever with joint pains in June 2020 and June 2022 for which she went to local hospital and treated conservatively. Negative History : No History of Headache,Hypertension,diabetes,Vomiting ,Chest Pain,Palpitations and Shortness of Breath, asthma  Past illness: patient was asymptomatic 12 years back and she developed abnormal uterine bleeding and swelling of uterus fibroids for which hysterectomy was done. History of epilepsy at the age of 6 years, u
Read more