SHORT CASE 2

 A 48 yr old male, farmer by occupation & resident of Nakrekal came to casualty with

CHEIF COMPLAINTS:

1.Swelling in the right lower limb since 20 years

   associated with pain 

2.Fever since 1wk

3.Loose stools  since 4 days (4 episodes/day)

HISTORY OF PRESENT ILLNESS  :

Patient  was apparently asymptomatic 20years back then, he developed

1) SWELLING IN THE RIGHT  LOWER LIMB :

 

 -Patient is a known case of filariasis with right leg swelling since 20    years which gets aggravated with rest and subsided with walking     intermittently also associated with fever spikes which gets relieved   with  medication

- Patient had a trauma over right lower limb 4 days back, following      which patient noticed increased swelling over right leg  with           ulceration and pus discharge associated with pain of pricking type.

 

2) FEVER :

- Low grade, intermittent type, associated  with chills & rigors, since    1 week & relieved by medications.

- He got admitted for the same in a nearby hospital and was told that

  his platelet count is low for which he was recieving conservative   

  treatment, as he could'nt afford the charges so was shifted here.

3)LOOSE MOTIONS:

-Patient had loose motions since 4 days , upto 4 episodes per day,

  not blood stained, non mucoid, low volume, non foul smelling. 

 No history of body pains, abdominal pain, head ache.

 No history of nausea ,vomitings or constipation.

 No history of oliguria or burning micturition.

 No history of any rashes or bleeding manifestations.

PAST HISTORY: 

- No similar complaints in the past

-Not a k/c/o DM, HTN, Asthma, TB, Epilepsy.

-No history of any drug usage or intake of toxins.

FAMILY HISTORY - 

-No significant family history 

PERSONAL HISTORY- 

- Diet              :mixed

- Appetite       :normal

- Sleep            : adequate 

- Bladder        : regular.

- Bowel          : diarrheoa since 4 days.

- Addictions   : Absent 

GENERAL EXAMINATION:

Patient is conscious, coherent, cooperative. 

well built, moderately nourished.

- No pallor 

- No icterus 

- No clubbing, cyanosis 

- No koilonychia

- Inguinal lymph nodes enlarged on right side,

- Non pitting edema of Right Leg  

- No rashes, Petechiae & Bleeding manifestations 

-Tourniquet test - Negative 

VITALS :

1.Temperature : Afebrile 

2. BP               : 100/70mmHg

3. PR               : 74 bpm

4. RR              :  24cpm.

SYSTEMIC EXAMINATION :

PER ABDOMEN:

- No distended abdomen

- No abdominal tenderness

- No engorged veins

- Guarding & rigidity absent

- Bowel sounds present.

RESPIRATORY SYSTEM:

-Bilateral airway entry present

-No added sounds

CVS :

- S1S2 Heard

- No thrills no murmurs

CNS:

-No abnormality noted

- Higher mental functions intact.

LOCAL EXAMINATION:

 ON LOCAL EXAMINATION:

Right leg appears to be swollen  with non pitting edema with skin 

changes with mild erythema.

skin appears dry with excoriation, with shallow skin folds.

No local raise of temperature, tender to touch.

No visible discharging sinuses.

PROVISIONAL DIAGNOSIS :

-ELEPHENTIASIS WITH CHRONIC LYMPHEDEMA (STAGE 1)

-DENGUE FEVER

 

FEVER CHARTING  :

SURGERY REFERRAL:

INVESTIGATIONS :

HEMOGRAM:

DATE : 4/08/21

- TOTAL WBC COUNT - 5,250 cells/cumm ( N - 4,000 to 10,000 cells/cumm)

- PLATELET COUNT  - 1.99 lakhs/cumm ( N - 1.5 - 4.1 lakh/cumm)

- PCV - 38.3% ( N - 40 - 50 %)

- 6/08/21

- TOTAL WBC COUNT - 3,500 cells/cumm 

- PLATELET COUNT  - 1.25 lakhs/cumm

- PCV - 46%

- 7/08/21

TOTAL WBC COUNT - 2,150 cells/cumm 

- PLATELET COUNT  - 44,000 cells/cumm 

- PCV - 39%

- 8/08/21 (MORNING)

- TOTAL WBC COUNT - 3,650 cells/cumm 

- PLATELET COUNT  - 39,000 cells/cumm 

- PCV - 39.4%

- 8/08/21 (EVENING)

- TOTAL WBC COUNT - 4,200 cells/cumm 

- PLATELET COUNT  - 60,000 /cumm 

- PCV - 39.1%

- 9/08/21 (Morning)

Evening 

DENGUE RAPID TEST 

MALARIAL PARASITE  TEST 

LFT

CUE

RBS

BLOOD UREA 

SERUM CREATININE 

SERUM ELECTROLYTES 

ECG 

TREATMENT 

DATE - 08/08/21

1. IVF @ 75 Ml/hr 

- 1. NS

- 1. RL

- 1. DNS

2. TAB PCM 650 MG X PO X TID

               1 - 1 - 1

Check temperature before giving pcm 

3. TEMPERATURE CHARTING 4TH HRLY

4. GRBS CHARTING 6TH HRLY

5. I/O CHARTING 

DATE - 9/09/21

1. IVF @ 75 Ml/hr 

- 1. NS

- 1. RL

- 1. DNS

2. TAB PCM 650 MG X PO X TID

               1 - 1 - 1

3. TAB AUGMENTIN 625 MG X OD X BD

4. TAB PAN 40 MG X OD

5. TAB MVT ORAL OD

6. TAB VIT C ORAL OD

7. TAB DOLO 650 MG ORAL (SOS)

8. Check temperature before giving pcm 

9. TEMPERATURE CHARTING 4TH HRLY

10.GRBS CHARTING 6TH HRLY

11. I/O CHARTING