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A 80 year old female, currently not working (used to be farmer by occupation),resident of Haliya was referred to medicine department with complaints of low haemoglobin level
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 2 months ago when she developed when she developed a swelling in perianal region which was insidious in onset and gradually progressive associated with fever.
15 days ago, the swelling eventually ruptured and was associated with discharge which was not associated with any discoloration or blood tinged , dull aching pain for which she was taken to a near by RMP where discharge was cleaned, dressing was done and IV antibiotics were administered.
5 days ago , patient was brought to casualty with similar complaints and was admitted in surgery department for further evaluation.
3 days ago, patient was shifted to medicine department due to low haemoglobin level (6.6 g/dl). Patient was given 1 unit of blood on 18/07/2023 and 4 units of blood on 19/07/2023.
PAST HISTORY
Patient is a known case of hypertension since 10 years for which she was started on anti hypertensives (currently on TAB Atenolol 50mg).
She for was diagnosed with Chronic kidney disease 6 months ago and was started on conservative management which were used for 2 months and gradually stopped due to complaint of experiencing side effects
She sought for psychiatric consultation 6 months ago for complaint of auditory hallucinations.
Not a k/n/o diabetes/TB/CVD/Epilepsy/Thyroid disorders
FAMILY HISTORY : Her younger daughter is known case of hypertension since 1 year.
TREATMENT HISTORY :
She is on anti hypertensives since 10 years
She is also on oral laxatives since 10 years.
SURGICAL HISTORY
30 years ago, she had complaints of diminision of vision in both eye with left >>right, was diagnosed with cataract in left eye and underwent cataract surgery in left eye.
14 years ago, for similar complaints in right eye, underwent cataract surgery in right eye. 10 to 15th post operative day, she started having double vision that slowly resolved.
PERSONAL HISTORY
Diet: Mixed
Appetite: decreased
Sleep: inadequate
Bowel and bladder movements: decreased urine output since one year ; irregular Bowel movements
Additions: She used to consume 1 sutta per day which was stopped 15 years back.
No history of recent Addictions
GENERAL EXAMINATION
Patient is conscious, coherent and cooperative oriented with time, place and person
Moderately built and nourished
No icterus, cyanosis, icterus, clubbing, lymphadenopathy, bilateral pedal edema
Right hand
CNS
Cranial nerves function intact
No focal neurological deficit
H/o auditory hallucinations currently suppressed due to increased pain in perianal region
RESPIRATORY
Inspection:
Chest is symmetrical and elliptical
no engorged veins
no scars or sinuses
Palpation:
Trachea is central in Position
Auscultation:
Normal vesicular breath sounds present
Bilateral air entry present
CVS
Inspection
Bilateral and Symmetrical chest movements seen
No engorged veins
No scars or sinuses
Palpation
Inspectory findings are confirmed
Apex beat is normal
Auscultation
S1, S2 heard
No murmurs
No thrills
PER ABDOMEN
Inspection
No abdominal distension seen
No scars or sinuses seen
No engorged veins
No peristalsis
No visible pulsations
Palpation
Soft and non tender
No hepatomegaly
no splenomegaly
Auscultation
bowel sounds heard
LOCAL EXAMINATION
Inspection: 2x2cm ulcer over the left perianal region, with sloping edges and purulent discharge. The discharge is foul smelling and slightly blood stained.
Palpation: Inspectory findings were confirmed. There is a local rise of temperature and tenderness over the ulcer. The ulcer measures 2x2x4cm and has pale granulomatous tissue. Pulses are normal and there is no regional lymphadenopathy.
INVESTIGATIONS
CHEST XRAY: Impression: Increased bronchovascular markings with B/L hilar enlargement
17/07/2023
INVESTIGATIONS
ECG
2D Echo: Impression:
- Trivial TR, No MR/AR
- No RWMA. No AS/MS. Sclerotic AV
- Good LV systolic function
- Diastolic dysfunction. No PE/PAH
- Right Grade II RPD changes
- Left Grade III RPD changes
- Right renal cortical cysts
- Left renal calculus
18/07/2023
19/07/2023
VITALS
FRESH FROZEN PLASMA:
19/7/23, 1AM: 1 UNIT
19/7/23, 2PM : 4 UNITS (started bag 1 at 2:05pm, ended bag 4 at 4:12pm)
IV FLUIDS NS UO+30ML/HR
TAB LORAZEPAM 1MG PO SOS
SYP ASCORYL 5ML ORAL TID
SYP APTIVATE (appetite stimulant)
INJ TETANUS TOXOID 0.5CC IM GIVEN ONCE
TAB BISACODYL PO/BD
INJ XYLOCAINE ID GIVEN ONCE AROUND THE SWELLING
INJ ERYTHROPOIETIN 4000IU SC 1/WEEK
TAB OROFER PO OD
INJ VITAMIN K
INJ LINEZOLID 600ML IV BD
INJ TRAMADOL 200ML IV BD
INJ NEOMOL 1GM IV SOS
TAB PANTOPRAZOLE 40MG PO OD
TAB ZOFER 4MG ORAL SOS
TAB NODOSIS 500MG PO OD
TAB SHELCAL PO OD
TAB OLANZAPINE 2.5MG PO OD
TAB PARACETAMOL 650MG PO BD
20/07/2023
22/07/2023
VITALS
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