60F WITH CAD CCF SINCE AUGUST 2023 WITH BLISTERING CELLULITIS SINCE SEPTEMBER 2023

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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.

Chief Complaints - 

60 year old female presented with complaints of ulcer over the left since 1 month. 

History of Present Illness - 

Patient was apparently alright 1.5 month ago when she developed blisters over left leg and foot which progressed to form a necrotic ulcer over the left leg.

She has associated loss of appetite and generalized weakness since 1 month.

It is associated with pain and intermittent fever. It is also associate with discharge.

No history of trauma.

No history of similar complaints in the past.

Past History - 

K/C/O HTN since 3 years, on Telma 20mg OD.

N/K/C/O DM, Asthma, TB, Epilepsy.

Sequence of Events - 

- History of backache since 15 years for which she did nnot use any medication.

- History of knee pain since 5 years for which she used to get injections from an RMP (4-5 injections/ month for the past 3-4 years)

- On September 18th, She developed cough with sputum and facial edema for which she had to be hospitalized. She was discharged the same day and recovered in about 1 week.

- On November 4th, She developed blisters over the ankle and lower leg. She was prescribed medication in a private hospital and was discharged.

- By November 8th, she developed generalized weakness, loss of appetite. She was hospitalized again and was diagnosed with necrotizing fascitis. She underwent debridement and excision and was discharged on november 12th.

- She continued to have a poor appetite, generalized weakness over the past month.

- On December 15th, She had to hospitalized again on worsening of her symptoms. She underwent further debridement and excision of the remaining necrotic tissue.

- On December 18th, she was admitted here with C/O chronic ulcer, loss of appetite and generalized weakness.

- She was transferred to the department of general medicine on the evening of 20th December over persistent hypoglycemia.

On NOVEMBER 6th - 

On NOVEMBER 10th - 

On NOVEMBER 21st - 

On NOVEMBER 26th - 

On DECEMBER 12th -

On DECEMBER 21st - 

Personal history - 

Addictions - None

Diet: non-vegetarian 

Apetite: decreased

Bowel and bladder: regular

Sleep: disturbed 

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative, moderately built and nourished.

Pallor: present

Icterus: absent

Cyanosis: absent

Clubbing: absent

Lymphadenopathy: absent

Pedal edema: absent

VITALS:

Temperature: 98 F

Pulse: 76 beats/minute

Blood pressure: 110/70mm Hg

Respiratory rate: 18 cpm

SYSTEMIC EXAMINATION - 

CVS - S1 S2 heard, no murmurs heard.

R/S - BAE present, NVBS heard

Trachea- central

P/A -

Soft, tender, no organo megaly

BOWEL SOUNDS HEARD

CNS - No focal deficit found.

Admitted on 18/12/23 in General surgery for cellulitis

Due to recurrent hypoglycemia patient was shifted to General medicine on 19/12/23

Given-25%Dextrose 

Grbs was 123 mg/dl @admission 

 On 20/12/2023

12 Am - 113.         

2 Am - 95

3 Am - 73 

4 Am - 72

4:30 Am -54

6 Am - 145

7 AM - 92

Pt shifted to ICU and 

Started 25%dextrose infusion @30ml/hr 

There was h/o starvation since 50 days 

So encouraged oral feeds simultaneously

Monitored grbs one hourly and tapered infusion rate from 30ml/hr to 5 ml/hr in 12 hrs

6 pm -161. 8 pm -235. 9 pm- 187. 11pm - 242     

21/12/23

12 Am -224. 6 AM -132.      

1Am - 172. 8 AM -141

2 Am -212 . 10 AM - 141

4 am - 178.    

Stopped infusion @12 pm, continued ryles feeding-ragi java ,protein powder in milk given

 12 PM - 136.     

2 pm -75 

8pm -118 

10 pm -124

22/12/23-morning-ragi malt

Afternoon-milk with protein powder

Eve-musk melon juice

12Am-40 6Am-90

2Am-70 8Am-62

4Am-100. 10Am-168

12pm-161. 2pm-75

23/12/2023-morning-milk with protein powder

Pt is not cooperative for ryles she removed it 

Afternoon-raagi malt

Again started on ryles

Eve-raagi malt

2 AM - 112. 10AM -147. 8PM - 147

4 AM - 118. 2PM -117. 10 PM -136

8 AM -163. 4 PM -168.   

24/12/2023-morning-milk

Afternoon-grape juice,water

Eve-raagi malt 

Again she took off ryles and non cooperative for ryles feeding 

2 AM -146. 2 PM -103 8 PM -110

8 AM -126. 4 PM -106.   

10 AM - 98. 6PM -108

25/12/2023

2 AM - 126 

6 AM - 110

8 AM -130