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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
Unit 6 admission
Amc cubicle bed 2
22 years old female daily wage labourer by occupation presented to the opd with c/o pain and swelling in left lower limb since 1 month .
HOPI
Patient was apparantly1year ago then she had round skin lesions which are associated with itching then they went to local doctor and used some topical ointment for period of 3-4 months patient did not got any relief so they again went to doctor then patient was prescribed with avil and decadran injections and patient used them for a period of 3-4 months even then patient did not got relieved from her skin lesions and then she came to our hospital and here she was given ?itraconazole later her skin lesions got subsided . 3 months ago then she had fever then she underwent some investigations and was found to be diabetic and was on medication TAB.METFORMIN 500MG PO OD and on INJ. MIXTARD S/C 6U--X--X .
H/o pain in the left lower limb since 1 month denies history of trauma later on swelling appeared which got burst with pus discharge and had underwent aseptic dressing for 1 week later it got progressed and patient is unable to walk due to pain .
H/o fever since 1-2 weeks on and off subsiding on taking medication , it is associated with nausea and no h/o vomiting ,loose stools .
H/o facial puffiness since 3 months .
Decreased urine output since 1 month .
She underwent LSCS due to delayed labour .
K/c/o DM since 3 months on tab metformin 500mg and inj. Mixtard 6u ---x---x
Not a K/c/o HTN, Asthma, Epilepsy , TB, CAD.
PERSONAL HISTORY
DIET :Mixed
Appetite : decreased
Bowels : c/o Constipation
Micturition : Decreased urine output .
No known allergies
No significant family history .
GENERAL EXAMINATION
Patient is conscious , coherant, cooperative.
No icterus , cyanosis , clubbing, lymphadenopathy.
Unilateral left lower limb edema pitting type .
Vitals :
Temp: 98.6
BP- 100/70 mmhg
PR- 92/min
RR- 18/ min
Spo2- 98%
Grbs- 372mg%
SYSTEMIC EXAMINATION
CVS - S1,S2 +
RS - BAE+
P/A- SOFT , NON TENDER ,BOWEL SOUNDS +
CNS - NO FOCAL NEUROLIGICAL DEFICITS
PROVISNAL DIAGNOSIS
? Iatrogenic Cushing's with h/o tenia corporis
K/c/o taenia corporis
LEFT LOWER LIMB CELLULITIS WITH UNCONTROLLED DIABETES MELLITUS .
TREATMENT
- IVF - NS , RL @100ML/HR
- INJ. PAN 40MG IV OD BBF
- INJ . NEOMOL 1GM IV SOS (IF TEMP> 101)
- INJ.HAI S/C TID
- TAB. DOLO 650MG PO SOS
- SYP . POTCHLOR 10 ML PO IN 1 GLASS OF WATER TID.
INVESTIGATIONS
CHEST XRAY PA VIEW
Doppler 13/11/21
SOAP NOTES
AMC CUBICLE BED2
22 YR OLD FEMALE
S:NO FREASH COMPLAINTS
O:
Pt is c/c/c
Temp
Bp: 110/60 mmhg
PR: 98/min
Cvs: s1,s2+
Rs: BAE+
P/A : SOFT, NONTENDER
BOWEL SOUNDS +
O :
UNCONTROLLED TYPE 2 DM WITH LOWER LIMB CELLULITIS
?IATROGENIC CUSHINGS WITH H/O TINEA CORPORIS
K/C/O TYPE 2 DM SINCE 3 MONTHS
P:
IVF - NS,RL
INJ.ZOSTUM 1.5GM IV BD
INJ. HAI S/C PREMEAL TID
INJ. TRAMADOL 1AMP IN 100ML NS IV BD
TAB. CHYMORAL FORTE PO TID
TAB . DOLO 650MG PO SOS
SYP. POTCHLOR 10ML PO
SOAP NOTES
Ward patient
22 YR OLD FEMALE
S: C/o pain in left lower limb
O:
Pt is c/c/c
Temp
Bp: 130/80 mmhg
PR: 78/min
Cvs: s1,s2+
Rs: BAE+
P/A : SOFT, NONTENDER
BOWEL SOUNDS +
O :
UNCONTROLLED TYPE 2 DM WITH LOWER LIMB CELLULITIS
?IATROGENIC CUSHINGS WITH H/O TINEA CORPORIS
K/C/O TYPE 2 DM SINCE 3 MONTHS
P:
IVF - NS,RL
INJ.ZOSTUM 1.5GM IV BD
INJ. HAI S/C PREMEAL TID
INJ. TRAMADOL 1AMP IN 100ML NS IV BD
TAB. CHYMORAL FORTE PO TID
TAB . DOLO 650MG PO SOS
SYP. POTCHLOR 10ML PO
SOAP NOTES
Ward patient
22 YR OLD FEMALE
S: C/o pain in left lower limb
O:
Pt is c/c/c
Temp :100.3
Bp: 120/80 mmhg
PR: 78/min
Cvs: s1,s2+
Rs: BAE+
P/A : SOFT, NONTENDER
BOWEL SOUNDS +
O :
UNCONTROLLED TYPE 2 DM WITH LOWER LIMB CELLULITIS
?IATROGENIC CUSHINGS WITH H/O TINEA CORPORIS
K/C/O TYPE 2 DM SINCE 3 MONTHS
P:
IVF - NS,RL
INJ.ZOSTUM 1.5GM IV BD
INJ. HAI S/C PREMEAL TID
INJ. TRAMADOL 1AMP IN 100ML NS IV BD
TAB. CHYMORAL FORTE PO TID
TAB . DOLO 650MG PO SOS
SYP. POTCHLOR 10ML PO
SOAP NOTES
Ward patient
22 YR OLD FEMALE
S: C/o pain in left lower limb
O:
Pt is c/c/c
Temp : 98.5
Bp: 120/70 mmhg
PR: 104/min
Cvs: s1,s2+
Rs: BAE+
P/A : SOFT, NONTENDER
BOWEL SOUNDS +
A :
UNCONTROLLED TYPE 2 DM WITH LOWER LIMB CELLULITIS
?IATROGENIC CUSHINGS WITH H/O TINEA CORPORIS
K/C/O TYPE 2 DM SINCE 3 MONTHS
P:
IVF - NS,RL
INJ.ZOSTUM 1.5GM IV BD
INJ. HAI S/C PREMEAL TID
INJ. TRAMADOL 1AMP IN 100ML NS IV BD
TAB. CHYMORAL FORTE PO TID
TAB . DOLO 650MG PO SOS
SYP. POTCHLOR 10ML PO
TAB.METFORMIN 500MG PO OD
Patient went on LAMA on 13/11/21
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