A 71yr male with decreased urine output since 4months,right lower limb cellulitis

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 A 71yr old male came to Casuality with 

CHIEF COMPLAINTS:

C/O of decreased urine output since 4months and right lower limb cellulitis and spreading ulcer over right lower limb.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently alright 4months back then he developed decreased urine output.

Patient had history of thorn prick injury on 27/08/23 and has consulted a local RMP for which he had done incision and drainage and then patientu developed swelling of right lower limb with boils over right ankle for which he consulted another hospital where they got to know that his creatinine levels are high and patient was referred to KIMS,NKP for hemodialysis.

C/o Fever which is on and off ,high grade,intermittent,associated with chills and rigors.

No c/o polyurea,nocturia,polydypsia

No tingling or burning sensation of b/l upper or lower limbs

No c/o chest pain,palpitations,orthopnea,PND 

No abdominal pain,vomiting,loose stools

He was referred to general surgery department I/V/o spreading ulcer over right lower limb ,they diagnosed it as AKI  with sepsis with spreading ulcer over right lower limb with DM for which below knee amputation with stump closure under SA was done on 12/09/23

PAST HISTORY:

K/C/O DM since 10 years (on medication)

Not a k/ c /o HTN,thyroid,TB,Epilepsy ,asthma 

3sessions of dialysis was done:

16/09/23

17/09/23

19/09/23

2 sessions of PRBC transfusion was done:

17/09/23

19/09/23

PERSONAL HISTORY:

Diet - mixed 

Appetite- normal

Sleep - adequate 

Micturition:- Normal 

Addictions :- alcohol consumption on alternate days since 25yrs (90ml whiskey per day)

Last intake of alcohol is 14days back

GENERAL EXAMINATION:- 

Patient is conscious and not oriented to to time and place

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

VITALS:

TEMPERATURE:- 98.8 F 

PR:81bpm

BP:90/60mmHg

RR:30cpm

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 examination:

No focal neurological deficit

HMF intact

PROVISIONAL DIAGNOSIS:

Chronic kidney disease (diabetic nephropathy) with k/c/o DM 2 since 10yrs

S/P below knee amputation 

INVESTIGATIONS:

TREATMENT:

1)IV Fluids

2)Inj.Meropenam 500mg IV / BD

3)Inj.Clindamycin 600mg IV/BD

4)Inj.Lasix 20mg IV/BD (if SBP > 110mmhg)

5)Inj.Neomol 1gm (if temp > 101F)

6)Inj.Human actrapid insulin according to grbs 

7)Inj.Noradrenaline (4ml+46ml NS) according to MA