General medicine case - 6

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CHIEF COMPLAINTS:-

22 years old female daily wage labourer by occupation presented to the opd with c/o pain and swelling in left lower limb since 1 month .

HOPI

Patient was apparantly asymptomatic 1year ago then she had  round skin lesions which are associated with itching then they went to local doctor and used some topical ointment for period of 3-4 months patient did not got any relief so they again went to doctor then patient was prescribed with avil and decadran injections and patient used them for a period of 3-4 months even then patient did not got relieved from her skin lesions and then she came to our hospital and here she was given ?itraconazole later her skin lesions got subsided . 3 months ago then she had fever then she underwent some investigations and was found to be diabetic and was on medication TAB.METFORMIN 500MG PO OD and on INJ. MIXTARD S/C 6U--X--X   .

H/o pain in the left lower limb since 1 month denies history of trauma later on swelling appeared which got burst with pus discharge and had underwent aseptic dressing for 1 week later it got progressed and patient is unable to walk due to pain .

H/o fever since 1-2 weeks on and off subsiding on taking medication , it is associated with nausea and no h/o vomiting ,loose stools .

H/o facial puffiness since 3 months .

Decreased urine output since 1 month .

She underwent LSCS  due to delayed labour .

K/c/o DM since 3 months on tab metformin 500mg and inj. Mixtard 6u ---x---x

Not a K/c/o HTN, Asthma, Epilepsy , TB, CAD.

 PERSONAL HISTORY

DIET :Mixed 

Appetite : decreased

Bowels : c/o Constipation

Micturition : Decreased urine output .

No known allergies 

No significant family history .

GENERAL EXAMINATION

Patient is conscious , coherant, cooperative.

No icterus , cyanosis , clubbing, lymphadenopathy.

Unilateral left lower limb edema pitting type .

Vitals :

Temp: 98.6 

BP- 100/70 mmhg

PR- 92/min

RR- 18/ min 

Spo2- 98%

Grbs- 372mg%

SYSTEMIC EXAMINATION 

CVS - S1,S2 +

RS - BAE+

P/A- SOFT , NON TENDER ,BOWEL SOUNDS +

CNS - NO FOCAL NEUROLIGICAL DEFICITS 

PROVISNAL DIAGNOSIS 

? Iatrogenic Cushing's with h/o tenia corporis

K/c/o taenia corporis 

LEFT LOWER LIMB CELLULITIS WITH UNCONTROLLED DIABETES MELLITUS .

TREATMENT

- IVF - NS , RL @100ML/HR

- INJ. PAN 40MG IV OD BBF

- INJ . NEOMOL 1GM IV SOS (IF TEMP> 101)

- INJ.HAI S/C TID 

- TAB. DOLO 650MG PO SOS 

- SYP . POTCHLOR 10 ML PO IN 1 GLASS OF WATER TID.

INVESTIGATIONS

SURGERY REFERAL 

FEVER CHART

ECG

CHEST XRAY PA VIEW

Doppler 13/11/21

SOAP NOTES 

AMC CUBICLE BED2

22 YR OLD FEMALE 

S:NO FREASH COMPLAINTS

O:

Pt is c/c/c

Temp 

Bp: 110/60 mmhg

PR: 98/min

Cvs: s1,s2+

Rs: BAE+

P/A : SOFT, NONTENDER

BOWEL SOUNDS +

O :

UNCONTROLLED TYPE 2 DM WITH LOWER LIMB CELLULITIS

?IATROGENIC CUSHINGS WITH H/O TINEA CORPORIS

K/C/O TYPE 2 DM SINCE 3 MONTHS

P:

IVF - NS,RL

INJ.ZOSTUM 1.5GM IV BD

INJ. HAI S/C PREMEAL TID

INJ. TRAMADOL 1AMP IN 100ML NS IV BD

TAB. CHYMORAL FORTE PO TID

TAB . DOLO 650MG PO SOS 

SYP. POTCHLOR 10ML PO

SOAP NOTES 

Ward patient

22 YR OLD FEMALE 

S: C/o pain in left lower limb

O:

Pt is c/c/c

Temp 

Bp: 130/80 mmhg

PR: 78/min

Cvs: s1,s2+

Rs: BAE+

P/A : SOFT, NONTENDER

BOWEL SOUNDS +

O :

UNCONTROLLED TYPE 2 DM WITH LOWER LIMB CELLULITIS

?IATROGENIC CUSHINGS WITH H/O TINEA CORPORIS

K/C/O TYPE 2 DM SINCE 3 MONTHS

P:

IVF - NS,RL

INJ.ZOSTUM 1.5GM IV BD

INJ. HAI S/C PREMEAL TID

INJ. TRAMADOL 1AMP IN 100ML NS IV BD

TAB. CHYMORAL FORTE PO TID

TAB . DOLO 650MG PO SOS 

SYP. POTCHLOR 10ML PO

SOAP NOTES 

Ward patient

22 YR OLD FEMALE 

S: C/o pain in left lower limb

O:

Pt is c/c/c

Temp :100.3

Bp: 120/80 mmhg

PR: 78/min

Cvs: s1,s2+

Rs: BAE+

P/A : SOFT, NONTENDER

BOWEL SOUNDS +

O :

UNCONTROLLED TYPE 2 DM WITH LOWER LIMB CELLULITIS

?IATROGENIC CUSHINGS WITH H/O TINEA CORPORIS

K/C/O TYPE 2 DM SINCE 3 MONTHS

P:

IVF - NS,RL

INJ.ZOSTUM 1.5GM IV BD

INJ. HAI S/C PREMEAL TID

INJ. TRAMADOL 1AMP IN 100ML NS IV BD

TAB. CHYMORAL FORTE PO TID

TAB . DOLO 650MG PO SOS 

SYP. POTCHLOR 10ML PO

SOAP NOTES 

Ward patient

22 YR OLD FEMALE 

S: C/o pain in left lower limb

O:

Pt is c/c/c

Temp : 98.5

Bp: 120/70 mmhg

PR: 104/min

Cvs: s1,s2+

Rs: BAE+

P/A : SOFT, NONTENDER

BOWEL SOUNDS +

A :

UNCONTROLLED TYPE 2 DM WITH LOWER LIMB CELLULITIS

?IATROGENIC CUSHINGS WITH H/O TINEA CORPORIS

K/C/O TYPE 2 DM SINCE 3 MONTHS

P:

IVF - NS,RL

INJ.ZOSTUM 1.5GM IV BD

INJ. HAI S/C PREMEAL TID

INJ. TRAMADOL 1AMP IN 100ML NS IV BD

TAB. CHYMORAL FORTE PO TID

TAB . DOLO 650MG PO SOS 

SYP. POTCHLOR 10ML PO

TAB.METFORMIN 500MG PO OD

Patient went on LAMA on 13/11/21