I am an intern in medicine department and one of the important terms of getting the internship completion is to complete my log book with my daily log of what I learn during the course of my duties.
Case presentation
This is a case of 55 yr old male, a farmer who presented with complaints of
1)pedal edema since 2 months , left sided gradually progressive swelling
2)pain and swelling in the left gluteal region
History of present illness:
Patient was apparently asymptomatic 2months back
Then patient noticed pedal edema , left side greater than right side pitting type gradually progressive not subsided with rest
Patient developed pain and swelling in the glutueal region since 1 month
History of fever on and off since 1 month not associated with chills and rigors relieved by medication
Patient is having difficulty in performing routine daily activities due to pain
Quack procedure was done over the swelling regions 15 days back
Patient developed pus points in the glutueal area with discharge after the procedure
Past history
Not a K/c/o HTN,DM, epilepsy,TB
H/O NSAID usage since 1 yr for knee joint pains since 1 yr
H/O haemorrhoids and bleeding PR 2 months back
Personal history
Appetite - normal
Diet- mixed
Bowels movements - constipated
Bladder- regular
Known alchoholic, since 10yrs - consumes daily 100ml per day
Knowm smoker since 10 years - 10 cigarattes - 5 pack years
Family history
Insignificant
General Examination
Patient is conscious, coherent, co-operative, moderately build and nourished.
No pallor, icterus, cyanosis , clubbing, lymphadenopathy
Pedal edema left sided pitting type
Pus points and scars present in the gluteal region
Vitals:
Temp:97.8f
Pulse:88bpm
BP:110/80mm hg
RR:18cpm
Systemic examination:
CVS:S1 S2 heard no murmurs
RS:BAE present
NVBS heard
ABDOMEN: Distended
Soft non tender
No organomegaly
Bowel sounds present
CNS:Intact
Investigations:
Haemogram
CUE
RFT
left lowe limb doppler
USG abdomen
RBS
HbA1c
ECG
Chest X-ray PA
Serology
ABG
PT- INR
APTT
BT/CT
Blood culture , sensitivity
Urine culture sensitivity.
Serum. Iron
Retic count
Stool for occult blood
Diagnosis
AKI with sepsis secondary to
Left lower limb cellulitis
Left gluteal abscess
Management
Inj. Metrogyl - 100ml iv /tid
Inj.vancomycin - 1.5gms iv stat in 100ml of NS followed by 500mg
Inj.Pantop - 40mg iv/bd
IVF - NS - U.O + 30ml/hr
T.Orofer XT /PO/BD
Left lower limb elevation
Regular dressing
