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

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.


This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.


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

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