50 YEAR OLD MALE
A 50 year old male goes to mobile shop as he's a shopkeeper in mobile shop
Ecg:
Diagnosis :
Another prbc done on 16/12/21 at 6.30pm
came to casualty with infected wound on right side of thigh ,he was admitted in surgery ,referred to gm i/v/o low haemoglobin
History of presenting illness:
patient was apparently asymptomatic 3 months ago where he had a bike accident and suffered injuries over his right thigh, right ankle and right palm for which he went to local hospital (an RMP doctor ) and got treated ( he got 2 stitches to his right knee )
After 1 month of the incident he developed fever(103 degree f ) for a day along with local rise of temperature at the site of wound for which he went to hospital where abscess was drained ,dressing of the wound was done for 3 days .
Later infection was spread to lateral part of knee due to which the surgical procedure was extended upto the lateral part of knee .Later on, the infection was extended upto thigh .and ulcer was formed for which debridement was done
During the hospital stay at nalgonda patient developed anuria for which foley's catheter was inserted (the attender's observation - from that day 9 am to around 6pm only 100 ml of urine was passed )
Dialysis was advised to the patient
1st dialysis was done in October ( total no.of dialysis done in that hospital -3 )
Later patient developed bradycardia for which he was taken to KIMS ,LB nagar where patient underwent 3 more dialysis' and for the ulcer VAC dressing was done.
After 1 month , they have come to KIMS , narketpally for the graft of ulcer but was referred general medicine due to low hemoglobin.
Past history :
Patient was diagnosed with diabetes mellitus 15 years ago and is on medication
5 years ago patient had dengue fever
2 months ago he was diagnosed with hypertension and is on medication
1 previous blood transfusion done in Kims lbnagar .
PERSONAL HISTORY :
Diet - Mixed
Appetite -normal
Bowel and bladder movements - regular
Addictions -
alcoholic since 20 years ,drinks 1 quarter daily
Last alcohol intake - 3 months ago
Family history :
Father(72 years ) was diagnosed with hypertension 5 years ago and is on medication now
GENERAL EXAMINATION :
Patient is conscious , coherent and cooperative
pallor +
No icterus , cyanosis , lymphadenopathy, edema .
VITALS
BP : 130/90 mm Hg
PR : 80 bpm
RR : 16/ MIN
SPO2: 98% on RA
SYSTEMIC EXAMINATION
CVS : S1, S2 +,no murmurs
RS : BAE + , NVBS
P/A : soft , nontender ,bowel sounds +
CNS : No focal neurological deficits
Investigations:
USG abdomen-
Reticulocyte count: 2.5%
Serum LDH:150
Ecg:
Ulcer over right thigh and knee with anemia under evaluation
Treatment :
1.On 14/12/2021 at 7:20 pm blood transfusion was initiated where pre transfusion , during transfusion and post transfusion vitals of the patient are stable.
2.Tab zincovit po/od
3.Tab zalra-m 50/500 po/od
4.Tab reclimet 80/500 1/2 po/bd
15/12/21
S-
No fresh complaints
1 prbc transfusion done yesterday at 7:20 pm . no fever spikes after the transfusion or during transfusion
O/E
Patient is conscious,coherent,cooperative
Temp -97.6° f
Bp - 120/70 mmHg
Pr - 90 bpm
RR - 16 cpm
Spo2 - 99%
Provisional Diagnosis:
Anemia under evaluation (nc nc ) with ulcer over right thigh with k/c/o diabetes mellitus with k/c/o aki (6 sessions hemodialysis done )
Treatment ;
1.no IV fluids
2.tab zincovit po/od
3.tab vildagliptin (50) + Metformin
4.tab gliclazide
5.bp ,pr,spo2 monitoring 8th hourly
6.Grbs charting 6th hourly
16/12/21
1 prbc done on 14th
No fever spikes ,No fresh complaints
O/E:
Patient is conscious,coherent,cooperative
Temp-afebrile
Bp -120/70mm Hg
Pr -87bpm
Spo2- 99% at RA
Grbs-303mg/dl
Provisional Diagnosis:
Anemia under evaluation (nc nc ) with ulcer over right thigh with k/c/o diabetes mellitus with k/c/o aki (6 sessions hemodialysis done )
Treatment:
1.no IV fluids
2.tab zincovit po/od
3.tab vildagliptin (50) + Metformin
4.tab gliclazide
5.bp ,pr,spo2 monitoring 8th hourly
6.Grbs charting 6th hourly
FBS- 156mg/dl
HbA1c -6.9%
Another prbc done on 16/12/21 at 6.30pm
