36 year old male with right lower limb pain since 3 months
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
A 37 years Old Male Auto Driver By Occupation came with Complaints of
Pain in Right Thigh Since 3 Months
Swelling of Right Thigh Since 3 Months
HOPI:
At the Age of 27 years Patient Noticed to Have Weight Loss & Had Fever For which he went to Hospital then his GRBS Was found to be above 500 & Treated with INSULIN & Discharge with
In Oct 2022 While Shifting a Rice Bag a Stone Fell on his Left Foot for which he went to RMP & Took Some Medication But it did not Heal Completely & Within 15days He Developed Swelling of Left LL Upto Knee for which he went to Some Private Hospital in Miryalguda where He Underwent Fasciotomy But Within 5-6 days after Surgery Swelling Increased & He was Informed that Infection ; Creatinine & Sugars Were Increased & Informed to go to Higher Centre & They Went to Another Hospital Where He Was Put on Foleys in v/o Abdominal Discomfort & Immediately 2 Urobags Were Filled & got Relieved of his Abdominal Discomfort & His Hemoglobin was 6.
Due to Affordability issues he came to Our Hospital ( Stayed For 1 week ) - Regular Dressing & PRBC Transfusion was done & was on Followup every 2 days for 1 Week.
But His left LL Swelling was Increasing Gradually So he was referred to Plastic Surgery in our Hospital & Was Planned for Surgery But Couldn't Be Done due to High BP & Was Planned for Surgery Later But Patient Denied & Went on LAMA. Then He Went to Some Local Hospitals & Gradually Healed.
He then developed pain in the right leg 4 months back which is aggrevated on walking
And it makes him stop for a while and then resume his walk.
He then had a burn injury to his left lower limb 2 months ago
2 days back he had fever Of high grade
PAST HISTORY:-
He is k/c/o Dm since 10 years and is on MOXTARD now and htn since 2 months and is on NICARDIA 20 mg.
N/C/K/O of epilepsy,TB
PERSONAL HISTORY:-
Patient is mpderately built and moderately nourished.
APPETITE:- normal
SLEEP:- disturbed due to leg pain
BOWEL AND BLADDER:- regular
ADDICTIONS :- 16 yr of alcohol history started 3 years before marriage consuming around >90 ml per day
No h/o smoking
FAMILY HISTORY:-
no similar complaints in the family.
He has a wife and 3 kids
All of them are healthy
GENERAL PHYSICAL EXAMINATION
Patient is concious coherent and cooperative, well oriented to time place and person.
Pallor +
Icterus -
Cyanosis -
Clubbing -
Lymphadepathy -
Edema +
Vitals
Bp -140/100
RR - 24
HR - 96
SPO2- 100 on 2lt O2
GRBS- 262 on on 19/4/23 around 6:45 pm
Temp- 99.7 F
SYSTEMIC EXAMINATION:-
CVS :- S1 and S2 are heard and no murmurs heard
RS :- BAE+, NVBS
PER ABDOMEN :- soft and non tender
CNS:- HMF Intact
Cranial nerves are intact
Tone:-
Right Left
UL LL UL LL
Normal couldn't be normal normal
elicited
Power:-
Right Left
UL LL UL LL
4/5 couldn't be 4/5 4/5
examined
Reflexes:-
Biceps:- right - normal left - normal
Triceps:- right- normal left- normal
Supinator:- right- normal left- normal
Knee:- right - not examined left - normal
Ankle:- right - not examined left - normal
Plantar:- right - mute left- mute
LOCAL EXAMINATION:-
local raise of temperature and tenderness is present
Joint mobility is restricted and patient is unbale to flex his knee
Distal pulses are felt.
INVESTIGATIONS:-
X Ray
ECG
USG ABD
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