Case 38 64 Male with ulcer over back since 10 days

Doa 3/8/24

Expired on 3/8/24

Diagnosis

ASPIRATION PNEUMONIA

LEFT IT FRACTURE 40DAYS BACK(CENTREIC)

GRADE IV BEDSORE OVER SACRAL REGION

HEART FAILURE SECONDARY TO CAD

K/C/O HTN AND DM II SINCE 2 YEARS

Case History and Clinical Findings

C/O ULCER OVER THE BACK SINCE 10DAYS

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 10DAYS BACK THEN NOTICED ULCER OVER

THE LOWER BACK REGION, INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE AND

ATTAINED A PRESENT SIZE OF APPROX 10X10CM ASSOCIATED WITH DISCHARGE-

PROFUSE, FOUL SMELLING, SEROPURULENT NOT ASSOCIATED WITH PAIN

C/O REDUCED URINE OUTPUT, POOR STREAM OF URINE SINCE 3 MONTHS

H/O CONSTIPATION PRESENT

NO H/O FEVER

PAST HISTORY:

K/C/O DM HTN SINCE 2 YEARS AND ON MEDICATION

H/O APPENDICECTOMY 32 YEARS BACK

H/O HYDROCELE 30 YEARS BACK

K/C/O GRADE II PROSTATOMEGALY AND ON MEDICATION

K/C/O CAD PRESENT AW STEMI/CHF

H/O IT FRACTURE 40 DAYS AGO NOT TREATED

PERSONAL HISTORY:

NORMAL APPETITE

CONSTIPATION PRESENT

DIET MIXED

NO ADDICTIONS

FAMILY HISTORY: NOT SIGNIFICANT

GENERAL EXAMINATION:

PATIENT IS CONCIOUS, COHERENT, IRRITABLE

NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY ,EDEMA.

TEMPERATURE: 98.6 F

BP: 110/70 MMHG

PR:80BPM

RR:22CPM

CVS: S1 S2 HEARD

NO MURMURS .

NO THRILLS .

RS: BAE+, NVBS, LEFT DIFFUSE FINE CREPTS HEARD

P/A:SOFT NON TENDER

NO PALPABLE MASS

NO ORGANOMEGALY

CNS:NO FOCAL NEUROLOGICAL DEFICIET.

ON EXAMINATION:

ON INSPECTION:

A 10X8CM ULCER IS SEEN OVER THE SACRAL REGION WHICH IS OVAL IN SHAPE WITH

WELL DEFINED BORDERS EXTENDING 2CMS ABOVE THE GLUTEAL CLEFT ON BOTH SIDES

BLACKISH NECROTIC PATCH PRESENT

SEROPURULENT DISCHARGE PRESENT

SURROUNDING SKIN-HYPERPIGMENTED

ON PALPATION:

NO LOCAL RISE OF TEMPERATURE

NO TENDERNESS

NECROTIC PATCH PRESENT COVERING ALL OVER THE ULCER

ALL INSPECTORY FINDINGS ARE CONFIRMED WITH RESPECT TO SIZE, SHAPE AND EXTENT

Investigation

HBsAg-RAPID 03-08-2024 04:14:PM Negative

Anti HCV Antibodies - RAPID 03-08-2024 04:14:PM Non Reactive

RAPID HIV TEST: NON REACTIVE

RFT 03-08-2024 04:14:PMUREA 71 mg/dl 50-17 mg/dlCREATININE 1.1 mg/dl 1.3-0.8 mg/dlURIC

ACID 5.2 mmol/L 7.2-3.5 mmol/LCALCIUM 10.0 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.4 mg/dl 4.5-

2.5 mg/dlSODIUM 141 mmol/L 145-136 mmol/LPOTASSIUM 4.3 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

98 mmol/L 98-107 mmol/L

LIVER FUNCTION TEST (LFT) 03-08-2024 04:14:PMTotal Bilurubin 1.21 mg/dl 1-0 mg/dlDirect

Bilurubin 0.58 mg/dl 0.2-0.0 mg/dlSGOT(AST) 38 IU/L 35-0 IU/LSGPT(ALT) 27 IU/L 45-0

IU/LALKALINE PHOSPHATASE 199 IU/L 119-56 IU/LTOTAL PROTEINS 6.4 gm/dl 8.3-6.4

gm/dlALBUMIN 2.5 gm/dl 4.6-3.2 gm/dlA/G RATIO 0.66

COMPLETE BLOOD PICTURE (CBP) 03-08-2024 04:14:PMHAEMOGLOBIN 10.0 gm/dl 17.0-13.0

gm/dlTOTAL COUNT 9300 cells/cumm 10000-4000 cells/cummNEUTROPHILS 80 % 80-40

%LYMPHOCYTES 15 % 40-20 %EOSINOPHILS 02 % 6-1 %MONOCYTES 03 % 10-2

%BASOPHILS 00 % 2-0 %PLATELET COUNT 2.0SMEAR Normocytic normochromic anemia

APTT TEST 32 SEC

PROTHROMBIN TIME 16SEC

INR 11.1

BLOOD GROUPING O POSITIVE

BLEEDING TIME 2MINS

CLOTTING TIME 4 MINS

RBS 116MG/DL

HBA1C : 6.9%

Treatment Given(Enter only Generic Name)

INJ PIPTAZ 2.25MG IV/BD

INJ METROGYL 500MG IV/TID

INJ PAN 40MG IV/OD

INJ TRAMADOL 1AMP/NS

TAB ECOSPIRIN 75MG PO/N/S

TAB CLOPIDOGREL 75MG PO/N/S

TAB ATORVAS 40MG PO/N/S

TAB LASIX 20MG PO/OD

TAB ALDACTONE 25MG PO/OD

TAB RAMIPRIL 2.5MG PO/OD

TAB MET-XL 12.5MG PO/OD

TAB METFORMIN 500MG PO/BD

Follow Up

64 YEAR OLD MALE RESIDENT OF NALGONDA CAME WITH COMPLAINTS OF ULCER OVER

LOWER BACK SINCE 10DAYS.

VITALS AT THE TIME OF ADMISSION BP-110/70MMHG, PR-98/MIN, GRBS- 121, SPO2-98%,

PATIENT WAS ADMITTED IN GENERAL SURGERY DEPARTMENT I/V/O GRADE IV BED SORE.

AT 6.30PM ON 3/8/24. PATIENT WAS TRANSFERRED TO GENERAL MEDICINE DEPARTMENT

I/V/O FURTHUR MANAGEMENT

PATIENT WAS SHIFTED TO ICU AND VITALS PR-92BPM, BP-100/60MMHG, RR-20CPM, SPO2-

96%.

AFTER DINNER PATIENT HAD SUDDEN GASPING AND FALL IN SATURATION

PATIENT HAD SUDDEN CARDIAC ARREST AND ABSENT CENTRAL PULSES AND INITIATED

CPR

AFTER 30MINS OF CPR PATIENT COULD NOT BE REVIVED AND DECLARED DEATH AT

10.30PM

IMMEDIATE CAUSE-

ASPIRATION

ANTECEDENT CAUSE-

HFPEF

LEFT IT FRACTURE 40DAYS BACK(CENTREIC)

GRADE IV BEDSORE OVER SACRAL REGION