GENERAL MEDICINE: 45 year old female

This is an online e-log platform to discuss case scenario of a patient with their guardians permission. 

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 histoty, clinical findings, investigations and come up with a diagnosis and treatment plan.

CASE:
A 45 year old female who is resident of Ramannapet  and by occupation An Anganvadi worker came to OPD on 09th of December  at 5:03 pm.

CHIEF COMPLAINS:
- Blisters formation on toe of lower limb one month back
-Patient complains of no urine output since 5 days
-Pain in abdomen since 5 days
-SOB since 2 days


HISTORY OF PRESENT ILLNESS:
-Patient was apparently asymptomatic from 1 month back.
-She developed blister over the toe which subsidid after taking treatment from govt hosp at Ramannapet.
-She was investigated & diagnosed with TYPE II DIABETES MELLITUS for the first time.
-T Metformin 500mg was given
-The blubs were formed again 5 days back and is extremely painful
-No H/O facial puffiness
-No H/O pedal edema
-No H/O burning micturition

HISTORY OF PAST ILLNESS:
- It is a k/c/c first time TYPE II DM on insulin
- It is N/k/c/o Hypertension, Asthama, Epilepsy

FAMILY HISTORY: not significant

PERSONAL HISTORY
Diet: mixed
Appetite: normal
Sleep: Adequate
Bowel and bladder:Irregular
Addictions: No
Allergies: No

GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative.
Well oriented to time, place and person.
Moderately built and well nourished.

Pallor: no
Icterus: no
Cyanosis: no
Clubbing of fingers: no
Lymphadenopathy: no
Pedal oedema: no

VITALS:
BP: 120/80mmHg 
PR: 82 bpm
RR: 16 cpm
SpO2: 98%

SYSTEMIC EXAMINATION:

CNS examination:
-Patient is conscious, coherent and cooperative.
-Speech is normal.
-Cranial nerves: intact

CVS examination:
-S1, S2 are heard.
-No murmurs.


Respiratory system examination:
-Inspection: Chest is moving bilaterally symmetrical. No pulsations.
-Palpation: Trachea is central in postion.
-Percussion: Resonant sound is seen.
-Auscultation: Breath sounds are vescicular.

Abdomen:
-Shape of abdomen: Scaphoid
-Tenderness: No
-Free fluid: No
-Liver : not palpable
-Spleen: not palpable
- Bowel sounds: Not Heard

Provisional diagnosis:
- AKI.


CLINICAL IMAGES:




INVESTIGATION:
-Hemogram
-Renal Function Test
-Blood Sugar
-ABG
-Anti Hcv Antibodies
-Ultra sound report
-Xray
-ECG
FINAL DIAGNOSIS:
.AKI
. Cellulitis
TREATMENT:
Rx
Inj PIPTAZ 2.25mg IV
Inj METROGYL 109ml TID
TAB Vitamin C PO BD
TAB MVT PO BD

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