A 50 year old male whose daily routine is to wake up in the morning , exercise and walk for an hour ,have his breakfast at around 8:30 am goes to his mobile shop as he's a shopkeeper in mobile shop and takes care of the real estate business the entire day and returns home back at around 8-9 pm
came to casualty with infected wound on right side of thigh ,he was admitted in surgery ,referred to gm i/v/o low haemoglobin
HOPI
patient was apparently asymptomatic 3 months ago where he had a bike skid while going from nalgonda to katangur suffered injuries over his right thigh ,right ankle and right palm for which he went to local hospital (an RMP doctor ) and got treated ( he got 2 stitches to his right knee )
After 1 month 15 days of the incident he developed fever(103 degree f ) for a day along with local rise of temperature at the site of wound for which he went to Navya hospital in nalgonda where abscess was drained ,dressing of the wound was done for 3 days . Later infection was spread to lateral part of knee due to which the surgical procedure was extended upto the lateral part of knee .Later on the infection was extended upto thigh .and ulcer was formed for which debridement was done
During the hospital stay at nalgonda patient developed anuria for which foley's catheter was inserted (the attender's observation - from that day 9 am to around 6pm only 100 ml of urine was passed )
Dialysis was advised to the patient i/v/o serum creatinine - 2.5 mg/dl
1st dialysis was done in October ( total no.of dialysis done in that hospital -3 )
Later patient developed bradycardia for which he was taken to KIMS ,LB nagar where patient underwent 3 more dialysis' and for the ulcer VAC dressing was put
After 1 month , they have come to KIMS , narketpally for the graft of ulcer but was referred general medicine I/v/o low hemoglobin.
Past history:
Patient was diagnosed with diabetes mellitus 15 years ago and is on medication (gliclazide and Metformin )
5 years ago patient had dengue fever
2 months ago he was diagnosed with hypertension and is on amlodipine
1 previous blood transfusion done in Kims lbnagar .
PERSONAL HISTORY
Marital status - married
Occupation - Mobile shopkeeper and real estate business man
Appetite - Normal
Diet - Mixed
Bowel and bladder movements - regular
Addictions -
alcoholic since 20 years ,drinks 1 quarter daily
Last alcohol intake - 3 months ago
Family history :
Father(72 years ) was diagnosed with hypertension 5 years ago and is on medication now
GENERAL EXAMINATION :
Patient is conscious , coherent and cooperative
pallor +
No icterus , cyanosis , lymphadenopathy, edema .
VITALS
BP : 130/90 MM HG
PR : 80BP MIN
RR : 16/ MIN
SPO2: 98% on RA
SYSTEMIC EXAMINATION
CVS : S1, S2 +,no murmurs
RS : BAE + , NVBS
P/A : soft , nontender ,bowel sounds +
CNS : No focal neurological deficits
Investigations :
USG abdomen
Reticulocyte count
Serum ldh
Diagnosis :
Ulcer over right thigh and knee with anemia under evaluation
Treatment :
1.On 14/12/2021 at 7:20 pm blood transfusion was initiated where pre transfusion , during transfusion and post transfusion vitals of the patient are stable.
2.Tab zincovit po/od
3.Tab zalra-m 50/500 po/od
4.Tab reclimet 80/500 1/2 po/bd
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