A 60 year old male k/c/o right below knee amputated lower limb with ? Cellulitis,pre renal AKI 2° to ?cellulitis ?nsaid abuse, acute liver injury with direct hyperbilirubinemia, hypoalbuminemia

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Here is a case i have seen:

70 yr old male came with 

C/o unilateral swelling in right post amputated leg since 4days 

Fever since 4days subsided on day2 

A/w vomitings since 4days 

7-8 episodes of vomiting in last 2days 

Decreased urine output 2days back 

Patient was apparently asymptomatic 4ays back then he noticed swelling in his right lowerlimb (amputated 3years back)when he was his way back from field which he went for digging a canal later he developed fever which was not associated with chills and rigors and was subsided on taking medication from local doctor .

It was associated with vomitings around 7-8 episodes for the past 2 days not subsiding and he was becoming weak .

He went to local doctor 

Routine investigations were done and was told he has a kidney problem and was referred to kamineni for further management 

Patient underwent below knee amputation 3years back at gandhi hospital and is using artificial leg since then

No h/o HTN,DM,TB ,asthma,epilepsy 

Personal h/o:

Patient takes mixed diet 

No loss of appetite 

Sleep adequate

Bowel and bladder movements normal 

Occasional alcoholic(?weekly once) 

O/e:

pt is c/c/c

No pallor, icterus, cynosis, clubbing, Lymphaenopathy

Pedal edema present

Vitals:

Pt was afebrile to touch

Pr-74bpm

Bp-130/80 mmhg 

Rr-18cpm

Cvs -s1s2 heard 

Rs-b/l air entry present 

P/a - soft ,non tender 

          No organomegaly 

          Bowel sounds present 

Cns-NFD 

CBP:

HB-12.3

TLC-11,000

PLT-1.64

CUE : 

COLOR -PALE YELLOW 

ALB-TRACE 

SUGAR -NIL

BILE SALTS AND PIG- NIL

PUS CELLS-3-4 

RBC -NIL

SPOT URINE PROTEIN-12

SPOT URINE CREAT-40.5

SPOT URINE A/G RATIO-0.29

Lft -

Tb-3.47

DB-2.69

SGOT-33

SGPT-21

ALP-729

ALB-2.52

RFT- 

UREA-150

CREAT-5

Na-134

K-4 

Cl-105

ABG:

PH -7.38

PCO2-27

PO2-89%

SO2-95%

HCO3-15.9

serology-negative 

Usg findings - b/l grade 1 RPD

ECG NORMAL 

CHEST XRAY - NORMAL

Treatment:

IVF-NS,RL @ U.O +50ml/hr(continuous)

Inj ceftrioxone 1 g/iv/bd

Inj pantop 40mg/iv/od

Inj zofer 4 mg/iv/bd

Inj lasix 20mg /iv/bd

2-3 egg whites per day 

protein powder in 1 glass of milk bd

Bp/pr/temp charting 4th hrly

stricy I/O charting

grbs 6th hrly

Surgery referal was done

Inj monocef 1g/iv/bd

inj metronidazole 500mg iv /bd

tab chymoral forte po tid

tab ultracet po/bd

food end elevation 

crepe bandage

Day 2:

C/o swelling of amputated limb, pitting type

C/o abdominal tightness

pt didn't pass stool today morning 

No c/o fever spikes since yesterday night

O/e:

Pt c/c/c

Afebrile to touch 

Pr-88bpm

Bp-130/80 mmhg 

Rr-16cpm

Grbs:127mg/dl

I/O:1300/1600

Cvs -s1s2 heard 

Rs-b/l air entry present ,b/l fine crepts(inspiratory) at infra axillary,infrascapular region

P/a - soft ,mild tenderness present at epigastric region ,No organomegaly , Bowel sounds present 

Cns-NFD 

Reports:

2d echo

Hb:12.2

Tlc:11,100

Plt:1.68

Pcv:34.3

Fbs:122

Plbs:174

HbA1c:6.6

Treatment:

IVF-NS,RL @ U.O +50ml/hr(continuous)

Inj ceftrioxone 1 g/iv/bd

Inj pantop 40mg/iv/od

Inj zofer 4 mg/iv/bd

Inj lasix 20mg /iv/bd

2-3 egg whites per day 

3 tsp of protein powder in 1 glass of milk bd

Bp/pr/temp charting 4th hrly & tepid sponging

stricy I/O charting

grbs 6th hrly

Inj monocef 1g/iv/bd

inj metronidazole 500mg iv /bd

tab chymoral forte po tid

tab ultracet po/bd

food end elevation  with 2 pillows 

crepe bandaging

MgSo4+glycerine dressing

Day 3:

C/o swelling of amputated limb 

C/o fever spike yesterday evening 

O/e:

Pt c/c/c

Temp:100.5

Pr-93bpm

Bp-120/70 mmhg 

Rr-18cpm

Grbs:104mg/dl

I/O:2800/2750

Cvs -s1s2 heard 

Rs-b/l air entry present , normal vesicular breath sounds heard 

P/a - soft ,mild tenderness present at epigastric region ,No organomegaly , Bowel sounds present 

Cns-NFD 

Reports:

urea:123

Creat:2.5

Na:147

K:3.7

Cl:103

TB:2.10

DB:1.00

AST:34

ALT:24

ALP:764

TP:6.3

ALB:2.5

A/G:0.70

CHEST X RAY:

Treatment:

IVF-NS,RL @ U.O +50ml/hr(continuous)

Inj ceftrioxone 1 g/iv/bd

Inj pantop 40mg/iv/od

Inj zofer 4 mg/iv/bd

Inj lasix 20mg /iv/bd(if sbp >110mmhg)

2-3 egg whites per day 

3 tsp of protein powder in 1 glass of milk bd

Bp/pr/temp charting 4th hrly & tepid sponging

stricy I/O charting

Inj monocef 1g/iv/bd

inj metronidazole 500mg iv /bd

tab chymoral forte po tid

tab ultracet po/bd

food end elevation  with 2 pillows 

crepe bandaging

MgSo4+glycerine dressing

Day 4:

No fresh complaints 

no fever spikes 

O/e:

Pt c/c/c

Temp:98.6

Pr-81bpm

Bp-110/80 mmhg 

Rr-18cpm

Grbs:101mg/dl

I/O:1700/2200

Cvs -s1s2 heard 

Rs-b/l air entry present , normal vesicular breath sounds heard 

P/a - soft ,non tender ,No organomegaly , Bowel sounds present 

Cns-NFD 

Reports:

Urea:96

creat:1.9

usg abdomen:

Treatment:

IVF-NS,RL @ U.O +50ml/hr(continuous)

Inj ceftrioxone 1 g/iv/bd

Inj pantop 40mg/iv/od

Inj zofer 4 mg/iv/bd

Inj lasix 20mg /iv/bd(if sbp >110mmhg)

2-3 egg whites per day 

3 tsp of protein powder in 1 glass of milk bd

Bp/pr/temp charting 4th hrly & tepid sponging

stricy I/O charting

Inj monocef 1g/iv/bd

inj metronidazole 500mg iv /bd

tab chymoral forte po tid

tab ultracet po/bd

food end elevation  with 2 pillows 

crepe bandaging

MgSo4+glycerine dressing