case 12.48 F with wound over left foot
DOA 19/4/24
DOD 29/4/24
Diagnosis
SEPTIC SHOCK WITH MULTIPLE ORGAN DYSFUNCTION (RESOLVED)
SECONDARY TO RIGHT DIABETIC FOOT
S/P: DISARTICULATION OF LEFT GREAT TOE(13/04/2024)
K/C/O TYPE 2 DIABETES MELLITUS SINCE 6 YEARS
K/C/O HTN SINCE 4 YEARS
1 PRBC TRANSFUSION DONE
Case History and Clinical Findings
CHIEF COMPLAINTS:
WOUND OVER THE RIGHT FOOT SINCE 4 MONTHS
HISTORY OF PRESENT ILLNESS:
PATIENT WAS APPARENTLY ASYMPTOMATIC 4 MONTHS BACK, AFTER WHICH SHE
DEVELOPED BLACKISH DISCOLORATION OF RIGHT GREAT TOE WHICH WAS INSIDIOUS IN
ONSET ,GRADUALLY PROGRESSIVE , ASSOCIATED WITH SWELLING OF THE INVOLVED
LIMB TILL MID FOOT FOR WHICH SHE WENT TO A LOCAL RMP AND WAS TREATED WITH
DRESSING .THERE WAS NO IMPROVEMENT, WITH PROGRESSION OF WOUND ,
ASSOCIATED WITH FOUL SMELLING DISCHARGE FOR WHICH SHE WAS TAKEN TO AN
OUTSIDE HOSPITAL WHERE DISARTICULATON OF RIGHT GREAT TOE WAS DONE UNDER
REGIONAL ANESTHESIA ON 13/04/24.
CAME ON LAMA TO OUR HOSPITAL FOR FURTHER MANAGEMENT
NO H/O FEVER,COUGH,COLD.
NO H/O CHEST PAIN,PALPITATIONS,BREATHLESSNESS,ORTHOPNEA,PND.
NO H/O ABDOMINAL PAIN,BURNING MICTURITION,NAUSEA,VOMITING.
HISTORY OF PAST ILLNESS:
K/C/O TYPE 2 DIABETES MELLITUS SINCE 6 YEARS (ON TAB GLIMI M1/OD),K/C/O HTN SINCE 5 YEARS
NO H/o,ASTHMA,TB,EPILEPSY,CVA,CAD,CKD,CLD.
TREATMENT HISTORY:
ON TAB.GLIMI-M1 PO/OD
PERSONAL HISTORY:
MARRIED
OCCUPATION: FARMER
APPETITE: NORMAL
DIET: MIXED
BOWEL AND BLADDER: REGULAR
KNOWN ALLERGIES: NO
ADDICTIONS: NO
FAMILY HISTORY:
NO SIGNIFICANT HISTORY.
GENERAL EXAMINATION :
PT IS CONCIOUS , COHERENT AND COOPERATIVE , MODERATLY BUILT AND NOURISHED .
PALLOR PRSENT.
NO ICTERUS , CYANOSIS, CLUBBING ,LYMPHADENOPATHY, EDEMA.
TEMP - 97.6 F
PR- 86 BPM
RR- 18 CPM
BP- 80/50 MMHG
SPO2- 98% AT RA
GRBS- 164 MG/DL
SYSTEMIC EXAMINATION :
CVS - S1,S2 HEARD , NO MURMURS
RS - VESICULAR BREATH SOUNDS HEARD , NO WHEEZE AND DYSPNEA,NO CREPTS
P/A- SOFT , NON-TENDER , NO ORGANOMEGALY
CNS -
LEVEL OF CONCIOUSNESS: CONCIOUS
SPEECH: INCOHERENT
SIGNS OF MENINGEAL IRRITATION: NEGATIVE
CRANIAL NERVES: NAD
MOTOR SYSTEM:
L R
TONE:UL- NORMAL NORMAL
LL- NORMAL NORMAL
POWER: 5/5 5/5
GLASGOW SCALE: E4V5M6
REFLEXES:
L R
BICEPS 2+ 2+
TRICEPS 2+ 2+
SUPINATOR + +
KNEE 2+ 2+
ANKLE NOT ELICITABLE +
PLANTARS- FLEXOR
GENERAL SURGERY ON 19/04/24 I/V/O DIABETIC ULCER OVER RIGHT FOOT: ADVICED PROTEIN DIET. (DIABETIC PROTEIN POWDER 2 TBSP IN GLASS OF MILK PO/BD)
2. T.CHYMEROL FORTE PO/TID.
3. BOTH LOWER LIMB ELEVATION.
4. REGULAR ASD( MGSO4 DRESSING FOR LEFT LOWER LIMB).
IONOTROPIC SUPPORT WAS STOPPED ON 23/4/2024 AND PATIENT IS HEMODYNAMICALLY
STABLE.
BLOOD TRANSFUSION (1 UNIT PRBC) DONE ON 25/04/2024 I/V/O HEMOGLOBIN - 7.6G/DL
.POST TRANSFUSION Hb 10.2 G/DL.
GENERAL SURGERY REFERRAL WAS DONE ON 24/04/24 I/V/O DIABETIC ULCER OVER LEFT
FOOT:
DEBRIDEMENT OF ULCER AND PAPAYA DRESSING DONE.
DURING THE STAY IN THE HOSPITAL , PATIENT WAS ACTIVELY AMBULATED . FROM DAY 4
OF ADMISSION HEALTHY GRANULATION TISSUE WAS FORMED IN THE WOUND.
PATIENT IS BEING DISCHARGED AS SHE SHOWED SIGNS OF PROGRESSIVE HEALING AND
IS HEMODYNAMICALLY STABLE, WITH GLYCEMIC CONTROL.
Investigation
HBsAg-RAPID 19-04-2024 10:26:PM Negative
Anti HCV Antibodies - RAPID 19-04-2024 10:26:PM Non Reactive
HIV 1/2 RAPID TEST: NON REACTIVE
URINE FOR CULTURE AND SENSTIVITY:
1-2 PUS CELLS SEEN.
PLENTY OF BUDDING YEAST CELLS SEEN.
NON ALBICANS CANDIDA >10* CFU/ML OF URINE.
SWAB FOR CULTURE AND SENSTIVITY:
FEW PUS CELLS,OCCASIONAL GRAM POSITIVE COCCI IN SINGLES SEEN,OCCASIONAL
GRAM NEGATIVE BACILLI SEEN.
NON ALBICANS CANDIDA ISOLATED.
BLOODFOR CULTURE AND SENSTIVITY:
NO GROWTH AFTER 48 HOURS OF AEROBIC INCUBATION.
USG ABDOMEN DONE ON 20/04/2024:
LIVER- NORMAL S/E,NO F/L
PV-NORMAL,NO IHBRD
CBD- NORMAL
GALL BLADDER- DISTENDED;WALL THICKNESS- NORMAL
PANCREAS- HEAD VISUALISED,NORMAL S/E
SPLEEN- 9.2 CM NORMAL S/E
RIGHT KIDNEY- 9.9 X 4.1 CM,NORMAL S/INCREASED ECHOGENICITY,CMD+
LEFT KIDNEY- 8.4 X 3.7 CM,NORMAL S/INCREASED ECHOGENICITY,CMD+
AORTA I.V.C. - NORMAL
NO ASCITES
NO LYMPHADENOPATHY
U.BLADDER- EMPTY,FOLEYS CATHETER INSERTED.
PELVIS COULD NOT BE ASSESSED.
IMPRESSION:
-RAISED ECHOGENICITY OF BILATERAL KIDNEYS.
2-D ECHO DONE ON 23/04/2024:
- NO RWMA.
- TRIVIAL TR+/AR+/MR+.
- MAC+ ; SCLEROTIC AV ; NO AS/MS.
- EF=59% ; RVSP=23+10=33MMHG.
- GOOD LV SYSTOLIC FUNCTION.
- GRADE 1 DIASTOLIC DYSFUNCTION+.
- MINIMAL PE+.
- IVC SIZE (0.8 CMS) COLLAPSING.
HEMOGRAM: 19/04/24
HB: 9.2 MG/DL
TLC: 23,500 CELLS/CUMM
N/L/E/M/B: 78/17/01/04/00
PCV: 27.8 VOL%
MCV: 79.6 FL
MCH: 26.4 PG
MCHC: 33.2 %
RBC COUNT: 3.48 MILLIONS/CUMM
PLATELET COUNT: 4.50 LAKHS/CU.MM
SMEAR:NORMOCYTIC NORMOCHROMIC
COMPLETE URINE EXAMINATION (CUE) 19/04/24
COLOUR: PALE YELLOW
APPEARANCE: CLEAR
REACTION: ACIDIC
SP.GRAVITY: 1.010
ALBUMIN: NIL
SUGAR: +
BILE SALTS: NIL
BILE PIGMENTS: NIL
PUS CELLS: 2-3
EPITHELIAL CELLS: 2-3
RED BLOOD CELLS: NIL
CRYSTALS: NIL
CASTS: NIL
AMORPHOUS DEPOSITS: ABSENT
OTHERS: EAST BUDING CELLS PRESENT
BLOOD UREA 19/04/24: 64 MG/DL
SERUM CREATININE: 1.3 MG/DL
SERUM ELECTROLYTES: 19/04/2024
SODIUM: 138 mmol/L
POTASSIUM: 3.4 mmol/L
CHLORIDE: 102 mmol/L
CALCIUM IONIZED: 0.96 mmol/L
LIVER FUNCTION TEST (LFT) 19/04/2024
Total Bilurubin: 1.70 mg/dl
Direct Bilurubin: 0.40 mg/dl
SGOT(AST): 20 IU/L
SGPT(ALT): 15 IU/L
ALKALINE PHOSPHATASE: 222 IU/L
TOTAL PROTEINS: 5.9 gm/dl
ALBUMIN: 2.7 gm/dl
A/G RATIO: 0.87
URINE FOR KETONE BODIES 20/04/2024: NEGATIVE
BLOOD LACTATE 20/04/2024 : 20 MG/DL
PERIPHERAL SMEAR 20/04/2024:
RBC: NORMOCYTIC NORMOCHROMIC
WBC: COUNTS INCREASED ON SMEAR
PLATELET: COUNTS INCREASED ON SMEAR
URINE PROTEIN/CREATININE RATIO 20/04/2024 :
SPOT URINE PROTEIN: 15.0 MG/DL
SPOT URINE CREATININE: 14.7MG/DL
RATIO: 1.02
24 HOURS CREATININE(URINE) 20/04/2024 : 0.46 G/DAY
APTT TEST 20/04/2024 : 32 SECONDS
BLOOD UREA 20/04/24 : 29 MG/DL
PROTHROMBIN TIME 20/04/2024 : 16 SEC
INR 20/04/2024 : 1.11
HEMOGRAM: 20/04/24
HB: 9.7 MG/DL
TLC: 18,100 CELLS/CUMM
N/L/E/M/B: 71/24/01/04/00
PCV: 29.0 VOL%
MCV: 80.4 FL
MCH: 26.8 PG
MCHC: 33.3 %
RBC COUNT: 3.60 MILLIONS/CUMM
PLATELET COUNT: 5.96 LAKHS/CU.MM
SMEAR:NORMOCYTIC NORMOCHROMIC
SERUM CREATININE 20/04/24 : 1.2 MG/DL
SERUM ELECTROLYTES: 20/04/24
SODIUM: 140 mmol/L
POTASSIUM: 3.2 mmol/L
CHLORIDE: 99 mmol/L
CALCIUM IONIZED: 1.0mmol/L
URINARY PROTEINS (24 HOURS) 20/04/24 :
24 HOURS URINARY PROTEIN: 38.7 MG/DAY
24 HOURS URINE VOLUME: 2,600
URINE PROTEIN/CREATININE RATIO 20/04/2024 :
SPOT URINE PROTEIN: 10.0 MG/DL
SPOT URINE CREATININE: 16.0 MG/DL
RATIO: 0.6
HEMOGRAM: 22/04/24
HB: 8.8 MG/DL
TLC: 18,000 CELLS/CUMM
N/L/E/M/B: 71/24/01/04/00
PCV: 27.3 VOL%
MCV: 81.7 FL
MCH: 26.2 PG
MCHC: 32.1 %
RBC COUNT: 3.34 MILLIONS/CU.MM
PLATELET COUNT: 5.96 LAKHS/CU.MM
SMEAR: NORMOCYTIC NORMOCHROMIC
SERUM MAGNESIUM 22/04/2024 : 1.9 MG/DL
SERUM POTASSIUM 22/04/2024 : 3.1 MG/DL
HEMOGRAM: 22/04/24
HB: 7.6 MG/DL
TLC: 16,500 CELLS/CUMM
N/L/E/M/B: 70/25/00/05/00
PCV: 23.2 VOL%
MCV: 81.1 FL
MCH: 26.7 PG
MCHC: 33.0 %
RBC COUNT: 2.86 MILLIONS/CU.MM
PLATELET COUNT: 5.0 LAKHS/CU.MM
SMEAR: NORMOCYTIC NORMOCHROMIC
SERUM ELECTROLYTES: 22/04/24
SODIUM: 131 mmol/L
POTASSIUM: 3.0 mmol/L
CHLORIDE: 105 mmol/L
CALCIUM IONIZED: 1.02 mmol/L
SERUM IRON 23/04/2024 : 44 UG/DL
HEMOGRAM: 23/04/24
HB: 7.6 MG/DL
TLC: 16,500 CELLS/CUMM
N/L/E/M/B: 70/25/00/05/00
PCV: 23.2 VOL%
MCV: 81.1 FL
MCH: 26.7 PG
MCHC: 33.0 %
RBC COUNT: 2.86 MILLIONS/CU.MM
PLATELET COUNT: 5.0 LAKHS/CU.MM
SMEAR: NORMOCYTIC NORMOCHROMIC
SERUM ELECTROLYTES: 24/04/24
SODIUM: 131 mmol/L
POTASSIUM: 3.0 mmol/L
CHLORIDE: 105 mmol/L
CALCIUM IONIZED: 1.02 mmol/L
SERUM ALBUMIN 24/02/2024: 2.48 G/DL
BLOOD GROUPING AND RH TYPING : B POSITIVE
HEMOGRAM: 26/04/24
HB: 10.3 MG/DL
TLC: 15,500 CELLS/CUMM
N/L/E/M/B: 71/22/01/06/00
PCV: 31.7 VOL%
MCV: 85.2 FL
MCH: 27.7 PG
MCHC: 32.5 %
RBC COUNT: 3.72 MILLIONS/CU.MM
PLATELET COUNT: 5.6 LAKHS/CU.MM
SMEAR: NORMOCYTIC NORMOCHROMIC ANEMIA WITH LEUCOCYTOSIS AND
THROMBOCYTOSIS
RFT 26/04/2024:
UREA: 21 mg/dl
CREATININE: 1.1 mg/dl
URIC ACID: 2.0 mmol/L
CALCIUM: 10.0 mg/dl
PHOSPHOROUS: 2.5 mg/dl
SODIUM: 138 mmol/L
CHLORIDE: 98 mmol/L
HEMOGRAM: 27/04/24
HB: 10.0 MG/DL
TLC: 15,100 CELLS/CUMM
N/L/E/M/B: 66/24/02/08/00
PCV: 30.3 VOL%
MCV: 84.4 FL
MCH: 27.9 PG
MCHC: 33.0 %
RBC COUNT: 3.59 MILLIONS/CU.MM
PLATELET COUNT: 5.2 LAKHS/CU.MM
SMEAR: NORMOCYTIC NORMOCHROMIC ANEMIA WITH LEUCOCYTOSIS AND
THROMBOCYTOSIS
SERUM BILIRUBIN TOTAL AND DIRECT 28/04/2024:
Total Bilurubin: 0.82 mg/dl
Direct Bilurubin: 0.20 mg/dl
SERUM ELECTROLYTES: 28/04/24
SODIUM: 136 mmol/L
CHLORIDE: 104 mmol/L
CALCIUM IONIZED: 1.16 mmol/L
FBS 132 mg/dl PLBS 169 mg/dl
HBA1C 7.0%
HEMOGRAM: 29/04/24
HB: 10.4 MG/DL
TLC: 12,600 CELLS/CUMM
N/L/E/M/B: 65/26/02/07/00
PCV: 32.6 VOL%
MCV: 82.8 FL
MCH: 26.4 PG
MCHC: 31.9 %
RBC COUNT: 3.93 MILLIONS/CU.MM
PLATELET COUNT: 5.2 LAKHS/CU.MM
SMEAR: NORMOCYTIC NORMOCHROMIC ANEMIA WITH LEUCOCYTOSIS AND
THROMBOCYTOSIS
SERUM POTASSIUM 29/04/2024 : 4.8 mmol/L
Treatment Given(Enter only Generic Name)
1. IV FLUIDS NS
2. INJ.PIPTAZ 4.5 GM/IV/TID
3. INJ.CLINDAMYCIN 600 MG/IV/BD
4. INJ.PAN 40 MG/IV/OD AT 8 AM
5. INJ.HUMAN ACTRAPID INSULIN S/C TID PRE-MEAL ACCORDING TO GRBS
6. INJ.NPH S/C BD PRE-MEAL ACCORDING TO GRBS
7. SYP.POTKLOR 15ML PO/BD IN A GLASS OF WATER (I/V/O HYPOKALEMIA )
8. AMBULATION AND POSITION CHANGE
9. REGULAR DRESSING OF LEFT FOOT
10.BP,PR,RR,SPO2 MONITORING 2ND HOURLY
Advice at Discharge
1. INJ.HUMAN ACTRAPID INSULIN S/C TID PRE-MEAL 12u---10u---6u ( 8 AM,1 PM,8 PM)
2. INJ.NPH S/C BD PRE-MEAL 10u---0---6u (8 AM, 8 PM)
3. HOME MONITORING OF GRBS ( PRE MEAL) 8 AM - 1PM - 8 PM)
4. TAB MVT PO OD
5.DEBRIDASE OINTMENT FOR LA
FOLLOW UP IN AUGUST 2024
FBS 120 PLBS 142 HBA1c 6.9
Wound healed
FOLLOW UP IN JANUARY 2025
FBS 107 PLBS 175 HbA1c 6.9
posted by Sri Govardhini @ May 04, 2025
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