A 45 YR OLD FEMALE

This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

DATE OF ADMISSION:9-12-2022

CHEIF COMPLAINT:
A 45 yr old female patient Anganwadi worker by occupation came to OPD with a C/O :
    -Blister formation on toe of Lower limb since 1 month
   - No urine output since 5 days 
   - Pain abdomen since 5 days 
   - SOB since 3 days 
   

HISTORY OF PRESENT ILLNESS:
- Patient Was apparently asymptomatic 1 month back.
- She developed blisters over toe which subsided after taking treatment at local government hospital ,treated by regular dressings
-At that time she was investigated and came to be diagnosed as DIABETES MELLITUS TYPE-II ,started with T metformin 500mg OD was given
- The blisters again formed 5 days back which were painful
- No H/O Facial puffiness
- No H/O Bilateral pedal edema
- No H/O Burning micturition 

HISTORY OF PAST ILLNESS:
 Is a K/C/O Diabetes mellitus II On insulin
 Not a K/C/O  HTN, Asthma, CAD, Epilepsy

PERSONAL HISTORY:
   Diet : mixed
   Appetite: normal
   Sleep : adequate
   Bowel and bladder movements: Irregular
   No addictions
   No allergies

GENERAL EXAMINATION:
- Patient is conscious,coherent and cooperative
Well oriented to time and place 
- No pallor

-No icterus

-No lymphadenopathy

-No cyanosis

-No clubbing of fingers 

-No pedal edema

VITALS:
Temperature-afebrile
Pulse rate -82 bpm
Respiration rate -16cpm
Bp-120/80 mm Hg
Spo -98%

 SYSTEMIC EXAMINATION:

🔹CNS :
- Speech is normal 
- cranial nerve: intact 

🔹CVS :
-S1, S2 are heard
- No murmurs


🔹Respiratory system :
- Inspection: chest is moving bilaterally symmetrical.No pulsations 
-palpation: Tachea is central in position
-percussion: Resonant sound
- Auscultation: Breathe sounds are vesicular 

🔹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:

INVESTIGATIONS:

   
 
 

FINAL DIAGNOSIS:
-AKI 
-Cellulitis

TREATMENT:

Inj PIPTAZ 2.25mg IV
Inj METROGYL 109ml TID
TAB Vitamin C PO BD
TAB MVT PO BD

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