PATIENT WITH RIGHT LOWER LIMB CELLULITIS
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PATIENT HISTORY:A patient named Malliah who is 60yr old male tailor by occupation visited our hospital on 18/02/2021.
CHEIF COMPLIANT: He came with the chief complaint of swelling in the right lower limb. History of trauma 2months back .
HISTORY OF PRESENT ILLNESS: patient was apparently asymptomatic for 10days and then developed swelling in right lower limb.onset at toe extending up to knee.
Associated with pain.c/o fever, burning micturition
HISTORY OF PAST ILLNESS: not a K/C/O diabetes mellitus, hypertension, tuberculosis, epilepsy
PERSONAL HISTORY
- the patient has no loss of appetite
- bladder movements are normal
-no sleep disturbances
- regular bowel ki
-normal micturition
FAMILY HISTORY:
No TB, asthma,stroke,cancer, hypertension, diabetes,heart diseases in the family members
TREATMENT HISTORY:
The patient is not a known case of drug allergy
GENERAL EXAMINATION:
-Patient is conscious,coherent and cooperative at the time of joining
-diffuse swelling extended hu up to knee.
-no ulcers
Pigmentation
Skin shiny
Tenderness
Local increase in temperature
Engorged veins
-No pallor
-No icterus
-No lymphadenopathy
-No cyanosis
-No clubbing of finger
VITALS - temperature:98.4F
-pulse rate:82bpm ki
-respiration rate:19/min
-bp:110/80
-spo2-98%
LOCAL EXAMINATION:
O/e lower limb diffuse swelling extended up to knee.
SYSTEMIC EXAMINATION:
RS: BAE+
CVS:S1 S2+
PA: SOFT,NON TENDER,
CNS: NAD
PROVISIONAL DIAGNOSIS:
Cellulitis
C/o swelling over right lower limb since 10days.
C/o associated with pain
H/o trauma present 2months back
No H/o similar complaints in past
No k/c/o , hypertension, diabetes, cardiovascular diseases,CAD, epilepsy.
INVESTIGATION:
PERSONAL HISTORY
- the patient has no loss of appetite
- bladder movements are normal
-no sleep disturbances
FAMILY HISTORY:
There are no similar complaints in the family members
TREATMENT HISTORY:
The patient is not a known case of drug allergy
GENERAL EXAMINATION:
-Patient is conscious,coherent and cooperative at the time of joining
-No pallor
-No icterus
-No lymphadenopathy
-No cyanosis
-No clubbing of fingers
-No edema of feet
VITALS - temperature:98.4F
-pulse rate:86bpm
-respiration rate:18/min
-bp:110/70
-spo2-98%
INVESTIGATIONS:
PERSONAL HISTORY
- the patient has no loss of appetite
- bladder movements are normal
-no sleep disturbances
FAMILY HISTORY:
There are no similar complaints in the family members
TREATMENT HISTORY:
The patient is not a known case of drug allergy
GENERAL EXAMINATION:
-Patient is conscious,coherent and cooperative at the time of joining
-No pallor
-No icterus
-No lymphadenopathy
-No cyanosis
-No clubbing of fingers
-No edema of feet
VITALS - temperature:98.4F
-pulse rate:86bpm
-respiration rate:18/min
-bp:110/70
-spo2-98%
PERSONAL HISTORY
- the patient has no loss of appetite
- bladder movements are normal
-no sleep disturbances
FAMILY HISTORY:
There are no similar complaints in the family members
TREATMENT HISTORY:
The patient is not a known case of drug allergy
GENERAL EXAMINATION:
-Patient is conscious,coherent and cooperative at the time of joining
-No pallor
-No icterus
-No lymphadenopathy
-No cyanosis
-No clubbing of fingers
- edema of feet
VITALS - temperature:98.4F
-pulse rate:86bpm
-respiration rate:18/min
-bp:110/70 ki
-spo2-98%
INVESTIGATION:
TREATMENT:
Soft diet
Injection Taxim1gm/w/BD.
Injection metrogyl 400 mg IV / tid
Injection PAN 40 mg IV/ od
Injection Tramadol 1am 200 ml
Nas IV/od
Glycerine+mgso4 dressing
Right lower limb elevation
Monitor vitals
Inform sos
PROGNOSIS:
The pus is removed from the limb and the swelling is reduced
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