65 Yr old male with cellulitis over right leg since 3 days

A 65 Yr old male patient presented to the casualty with chief complaints of swelling over right leg since 3 days 

HISTORY OF PRESENT ILLNESS :-

Patient was apparently asymptomatic before 10 days and then he apparently developed swelling over the right limb secondary to trauma by an iron nail which led to formation of blisters in the posterior aspect of leg.

There is H/o fever (3 episodes) associated with chills and rigors on 3 consecutive days after the day of admission into hospital which occurred only during morning and subsided after taking medication.

The patient is a farmer by occupation and his injury occurred when he suddenly stepped on an iron nail in his field when he was ploughing with his bullocks.

There is no H/o urinary retention

No H/o chronic cough or evening rise of temperature 

No H//O fever, burning micturition, loose stools

No H/O sob, palpitations

PAST HISTORY :- 

Not a known case of DM,HTN,Epilepsy,TB and coronary artery disease.

PERSONAL HISTORY :-

Diet - mixed

Appetite - normal

sleep - adequate

Bowel and Bladder movements - regular

Addictions - Consumes alcohol regularly since the past 15 yrs

DRUG HISTORY : 

No significant drug history

FAMILY HISTORY :-

No significant family history

GENERAL EXAMINATION :-

Patient is conscious , coherent , cooperative

at the time of examination

He is examined in a well lit room, with consent taken.

He is moderately built and well nourished.

Pallor - absent

Icterus - absent

Cyanosis - absent 

Clubbing - absent

lymphadenopathy - absent

Pedal edema - absent

Vitals :

Temperature - Afebrile

Pulse rate - 92 bpm

Respiratory rate - 28 cpm

Blood pressure - 90/60 mmHg

SpO2 - 94% on Room air

GRBS - 107 mg/dl

SYSTEMIC EXAMINATION :-

CVS :- S1 and S2 heart sounds heard

           NO murmurs and thrills

RESPIRATORY SYSTEM :- Bilateral air entry present position of trachea - central Vesicular breathsounds heard

CNS :- no focal neuroligical deficit

ABDOMEN :- Soft and non tender

            No palpable masses

            Bowel sounds heard 

            No organomegaly

INVESTIGATIONS :-

RFT :-

urea - 124

Creat - 3.3

UA - 6.6

Ca - 8.5

P - 3.7

Na - 136

K - 3.2

Cl - 105

LFT :-

TB - 4.69

DB - 4.6

SGOT - 59

SGPT - 25

AIP - 480

TP - 4.4

albumin - 2.41

A/G - 1.28

CBP :-

Hb - 11.5

TLC - 19000

N - 76

L - 13

E - 01

M - 10

B - 00

PLT - 74000

ULTRASOUND CHEST - impression -

Bilateral moderate pleural effusion with collapse and air bronchograms on the right side

TREATMENT:-

IVF fluids NS, RL @75ml/hr

INJ. OPTINEURON 1 ampoule in 500ml ns IV/OD

INJ. PIPTAZ 2.25 G IV/TID

INJ METROGYL 500 MG/ IV/ TID

INJ ZOFER 4 MG/ IV/ TID

INJ PAN 40 MG IV/ OD

TAB CHYMEROL FORTE PO/BD

TAB PCM 650 MG PO/TID

NEB WITH IPRAVENT 6TH HRLY AND BUDECORT 12 HRLY

STRICT IO CHARTING

VITALS MONITORING

PROVISIONAL DIAGNOSIS:-

Sepsis with MODS with DIC (resolving) secondary to right lower limb cellulitis with bilateral transudative pleural effusion with hypokalemia