PATIENT WITH RIGHT LOWER LIMB CELLULITIS

 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 input.

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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