INTERN'S E- LOG

 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