A 78yr old male with prerenal AKI ,left LL cellulitis

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A 78 yr old who is a resident of Nalgonda came to Casuality with

CHIEF COMPLAINTS:

Swelling of left lower limb since 15 days

C/O decreased urine output since yesterday

HISTORY OF PRESENTING ILLNESS:

Patient was apparently alright 15 days back then he had a swelling at the left lower limb which is insidious in onset gradually progressive 

There was a history of fever 15 days back for 3 days low grade relieved by taking medication ,not associated with chills and rigors

Decreased urine output since yesterday.

No h/o cold ;cough; chest pain ; palpitations 

No c/o SOB 

PAST HISTORY:

K/c/o HTN since 8 years on irregular medication 

Not a K/c/o DM; epilepsy ; CAD; CVA;TB

6 years back he had cellulitis of left lower limb

He had a history of fracture of left tibia for which interlocking mail has been used then he developed necrotising fasciitis and then cellulitis of left lower limb then implant has been removed 5yrs ago.

FAMILY HISTORY:

No significant family history

PERSONAL HISTORY:

DAILY ROUTINE:

He used to work as a shopkeeper but he stopped working 10yrs back.He will wake up at 7am in the morning ,has breakfast at around 9am, rest for 1hr and has lunch at around 1:30pm sleep for 2hrs ,watches TV has dinner at 8pm and goes to bed by 10pm.

Diet-mixed

Appetite-normal

Bowel and bladder movements-normal

Sleep-adequate

Occasional alcohol consumption

GENERAL EXAMINATION:

Patient is conscious,coherent,cooperative and well oriented to time ,place and person

No signs of pallor ,icterus,cyanosis,clubbing,lymphadenopathy

B/L pedal edema+

SYSTEMIC EXAMINATION:

CVS examination:

No visible pulsations, scars, engorged veins. No rise in jvp 

Apex beat is felt at 5 Intercoastal space medial to mid clavicular line.

 S1 S2 heard . No murmurs.

Respiratory system :

Shape of chest is elliptical, b/l symmetrical.

Trachea is central. Expansion of chest is symmetrical

 Bilateral Airway Entry - positive

 Normal vesicular breath sounds

Per Abdominal examination: 

Soft , non tender

bowel sounds heard

CNS  : 

No focal neurological disorder found 

Normal speech

PROVOSIONAL DIAGNOSIS:

Prerenal AKI with left lower limb cellulitis

TREATMENT:

1)Inj Meropenem 1gm IV/BD 

2)Inj.Metrogyl 500mg IV/TID 

3)Inj.Pan 40mg IV/OD

4)Inj.Lasix 80mg IV/TID

5)Tab.Chymerol forte PO/TID

6)Tab.MVT PO/OD

7)Tab.Vit C PO/OD

8)Tab.Ecosprin AV 75/10 PO H/S

9)Tab.MET XL 25mg PO/OD

10)MGSO4 + Glycerine dressing of left LL

11)left lower limb elevation

CHEST X-RAY PA VIEW:

ECG:

27/08/23

Serology-negative

CRP - negative

CUE:

Albumin:++

Sugars:nil

Pus cells:3-4

Epithelial cells:2-3

Hemogram:

Hb-9.5gm/dl

TLC-9,800

N/L/E/M/B-73/15/02/10/00

PCV-27.8vol%

Platelet count-3.47 lks/cu.mm

LFT:

Total bilirubin:1.10 mg/dl

Direct bilirubin: 0.25 mg/dl

Alkaline phosphatase:227* IU

AST:19 IU

ALT:17 IU

Protein total: 6.1 G/DL

Albumin:3.0g/dl

Albumin and globulin ratio:1.01

RFT:

Urea-40mg/dl

Creatinine-1.8mg/dl

Uric acid-7.4mg/dl

Ca+  9.7mg/dl

Po4  4.0mg/dl

Na+  136mEq/L

K+  4.0mEq/L

Cl-  99mEq/L

28/08/23

Hemogram:

Hb-9.3gm/dl

TLC-9,400

N/L/E/M/B-75/13/02/10/00

PCV-26.7vol%

Platelet count-3.27 lks/cu.mm

RFT:

Urea-45mg/dl

Creatinine-1.8mg/dl

Uric acid-7.7mg/dl

Ca+  9.0mg/dl

Po4  3.6mg/dl

Na+  133mEq/L

K+  3.6mEq/L

Cl-  98mEq/L

29/08/23

Hemogram:

Hb-9.3gm/dl

TLC-8,900

N/L/E/M/B-65/20/05/10/00

PCV-26.4vol%

Platelet count-3.54 lks/cu.mm

RFT:

Urea-49mg/dl

Creatinine-1.8mg/dl

Uric acid-8.1mg/dl

Ca+  9.2mg/dl

Po4  3.7mg/dl

Na+  129mEq/L

K+  3.9mEq/L

Cl-  96mEq/L

30/08/23

RFT:

Urea-47mg/dl

Creatinine-1.6mg/dl

Uric acid-8.4mg/dl

Ca+  9.3mg/dl

Po4  4.2mg/dl

Na+  122mEq/L

K+  4.3mEq/L

Cl-  96mEq/L

Ferritin-174.9ng/ml

Reticulocyte count-0.8%

Serum iron-71.2ug/dl

Serum osmolality-250.5m osm/kg

URINARY ELECTROLYTES:

Na+  123mmol/L

K+  6.6mmol/L

Cl-  159mmol/L

31/08/23

RFT:

Urea-44mg/dl

Creatinine-1.5mg/dl

Uric acid-8.5mg/dl

Ca+  9.0mg/dl

Po4  4.1mg/dl

Na+  126mEq/L

K+  3.9mEq/L

Cl-  96mEq/L

1/09/23

RFT:

Urea-43mg/dl

Creatinine-1.5mg/dl

Uric acid-9.6mg/dl

Ca+  8.9mg/dl

Po4  4.1mg/dl

Na+  130mEq/L

K+  3.8mEq/L

Cl-  98mEq/L

SOAP NOTES:

30/08/23

Date of admission : 27/08/23

Dr.Rakesh Biswas (HOD)

Dr.Sushmitha (SR)

Dr.Nishitha (PGY2)

Dr.Navya (PGY1)

S

Patient complaints of left lower limb swelling 

Burning micturition +

No complaints of fever,vomitings,loose stools

O

Patient is conscious/coherent/cooperative 

Temp:96.4F

Bp: 110/80  mmhg

PR: 79 bpm, regular 

RR: 24 cpm

SPO2: 98% at RA

CVS: S1 S2+ , no murmurs heard

RS: Bilateral air entry+, NVBS heard

CNS: NFAD

P/A: Soft, no organomegaly, bowel sounds heard 

A

Left lower limb cellulitis with prerenal AKI

HFpEF secondary to CAD

P

1)IV fliuds NS @50ml/hr

2)Inj Meropenem 1gm IV/BD

3)Inj.Metrogyl 500mg IV/TID

4)Inj.Pan 40mg IV/OD

5)Inj.Lasix 80mg IV/TID

6)Tab.Chymerol forte PO/TID

7)Tab.MVT PO/OD

8)Tab.Vit C PO/OD

9)Tab.Ecosprin AV 75/10 PO H/S

10)Tab.MET XL 25mg PO/OD

11)MGSO4 dressing

12)left lower limb elevation

31/08/23

Date of admission : 27/08/23

Dr.Rakesh Biswas (HOD)

Dr.Sushmitha (SR)

Dr.Nishitha (PGY2)

Dr.Navya (PGY1)

S :

Patient complaints of left lower limb swelling 

Burning micturition has been resolved

No complaints of fever,vomitings,loose stools

O :

Patient is conscious/coherent/cooperative 

Temp:96.4F

Bp: 120/90  mmhg

PR: 78 bpm, regular 

GRBS : 121 mg/dl

SPO2: 98% at RA

CVS: S1 S2+ , no murmurs heard

RS: Bilateral air entry+, NVBS heard

CNS: NFAD

P/A: Soft, no organomegaly, bowel sounds heard 

A :

Left lower limb cellulitis with prerenal AKI

HFpEF secondary to CAD

P :

1)IV fliuds NS @50ml/hr

2)Inj Meropenem 1gm IV/BD (D5)

3)Inj.Metrogyl 500mg IV/TID (D5)

5)Inj.Lasix 80mg IV/TID

6)Tab.Chymerol forte PO/TID

8)Tab.Vit C PO/OD

9)Tab.Ecosprin AV 75/10 PO H/S

10)Tab.MET XL 25mg PO/OD

11)MGSO4 + Glycerine dressing

12)left lower limb elevation

01/09/23

Date of admission : 27/08/23

Dr.Rakesh Biswas (HOD)

Dr.Sushmitha (SR)

Dr.Kranthi (PGY2)

Dr.Navya (PGY1)

S :

Patient complaints of left lower limb swelling,c/o foreign body sensation in left ear since yesterday night

No complaints of fever,vomitings,loose stools

O :

Patient is conscious/coherent/cooperative 

Temp:98.5F

Bp: 130/80  mmhg

PR: 64 bpm, regular 

SPO2: 98% at RA

CVS: S1 S2+ , no murmurs heard

RS: Bilateral air entry+, NVBS heard

CNS: NFAD

P/A: Soft, no organomegaly, bowel sounds heard 

A :

Left lower limb cellulitis with prerenal AKI

HFpEF secondary to CAD

Anemia

P :

1)Inj Meropenem 1gm IV/BD 

2)Inj.Metrogyl 500mg IV/TID 

3)Inj.Pan 40mg IV/OD

4)Inj.Lasix 80mg IV/TID

5)Tab.Chymerol forte PO/TID

6)Tab.MVT PO/OD

7)Tab.Vit C PO/OD

8)Tab.Ecosprin AV 75/10 PO H/S

9)Tab.MET XL 25mg PO/OD

10)MGSO4 + Glycerine dressing of left LL

11)left lower limb elevation

[29/08/23, 4:36:05 PM] Rakesh Biswas Sir: Left leg? What's the radiological diagnosis? Why is the tibia bent?

[29/08/23, 4:39:08 PM] Tejaswini Kandhada: Yes sir it is left leg

[30/08/23, 3:20:19 PM] Rakesh Biswas Sir: 👆two questions unanswered

[30/08/23, 3:20:48 PM] Rakesh Biswas Sir: How was HFpEF diagnosed?

[30/08/23, 3:39:20 PM] Tejaswini Kandhada: His apical impulse felt at 6 th intercostal space sir

X ray shows cardiomegaly and in 2decho all chambers are dialted with normal ejection fraction sir

[30/08/23, 4:07:49 PM] Rakesh Biswas Sir: Dilated heart and preserved ejection fraction would be unusual. 

Please share his chest X-ray, Ecg and Echo video

[30/08/23, 4:30:27 PM] Tejaswini Kandhada: He had H/O left tibia fracture 8yrs back for which interlocking nail has been used then after 2yrs of implant he has developed necrotising fasciitis and cellulitis after that implant has been removed sir

[30/08/23, 4:30:41 PM] Tejaswini Kandhada: It might be malunion sir

[31/08/23, 6:57:10 PM] Rakesh Biswas Sir: Image of his cellulitis?

[31/08/23, 6:57:23 PM] Rakesh Biswas Sir: Case report link?

[01/09/23, 10:31:11 PM] Rakesh Biswas Sir: Well healed