65 year old male with CKD, necrotising fascitis-Prefinal
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Chief compliants:
1) Altered sensorium since 1 day.
2) Swelling associated with pain in the left back region since 5 days.
History of present illness :
65 year old male who is a manson worker by occupation was apparently asymptomatic since 10 years of age, then went to the work near the village head house daily and this continued for around 5 years.
At 15 years of age his father died and patient used to stay with his own brother and he used to send him to the work ( construction work ) and he used to get rs-20/- daily and used to give this money to his brother and instead inreturn he gave food and shelter to his brother.
After 6 years at around 21 years of age , patient got married and seperated from his brother and started leaving themselves.
He used to go to the construction work and also used to take care of his agriculture field and patient had 4 children ( 3 daughters and 1 children ).He had 3 acres of agriculture land and used to grow paddy in his field.
He used to take alcohol 90-180ml/ day and used to smoke around 1 packet of beedis per day.
After 3 years of marriage,his 1st daughter was born and after 5 years of marriage -son and after 8 years of marriage -3rd daughter and after 10years of marriage -4th daughter.
Around 10 years back, patient had trauma to the left big toe ( injury by stone ) and as it was no healing patient went to the hospital and found to be denovo diabetic and toe was amputated and he stopped his work as manson worker and only used to take care of agriculture.
Unable to recall but , patient had such similar episodes of toe amputation around 3 times .
6 years back , on routine follow up with the doctor , patient was told to have renal issue( renal parameters are not known ).
4 years back, on regular follow up with the doctor,found to have hypertension and started on antihypertensives, but not on regular medication.
2 years back , patient developed abdominal pain, and weakness in the both lower limbs which gradually progressed over 1 week and the weakness improved after 25 days and patient was started on Insulin from then.
1 week back before admission, patient was travelling on the Luna and suddenly near parking the vehicle ,there was large stone which he didn't and had skid and fall with injury over the left posterior back region.
It was followed by swelling associated with pain in that region ,which was gradually progressing day by day.The patient was taken to government hospital,where local incision and drainage was done following next day since morning, patient unable to open his eyes and was not properly responding to oral commands,then they brought here for further evaluation.
Past history:
Known Diabetes since 10years
Known hypertension since 4 years
Known Case of chronic kidney disease since 6 years.
GENERAL EXAMINATION:
No pallor ,icterus,clubbing,cyanosis,lymphadenopathy.
Pedal edema.
SYSTEMIC EXAMINATION:
BP: 120/80
PR;80BPM
CVS:S1S2+
RS; BAE+
P/A: SOFT,NON TENDER
PERIPHERAL ARTERY PULSATIONS :
B/L dorsalis pedis - unable to feel, posterior tibial ( feeble ).
Popliteal artery - felt
Tone
Right. Left
Upper limb. Normal. Normal
Lower limb. Normal. Normal
Reflexes
Right. Left
Biceps. - -
Triceps. - -
Supinator. - -
Knee. - -
Ankle. - -
Plantar. - -
Power
Uperlimb. Right. Left
Deltoid. 4+ 4+
Supraspinatus. 4+ 4+
Infraspinatus. 4+ 4+
Rhomboids. 4+ 4+
Lumbricals. 4+ 4+
FHL. 4+ 4+
FDL. 4+ 4+
EHL. 4+ 4+
EDL. 4+ 4+
Lowerlimb
Right. Left
Gluteus ,hamstrings ---4 4
Iliopsoas. 4. 4
Adductor femoris. 4. 4
Gastronemius. 4+ 4+
Peroneai. 4+ 4+
Tibialis anterior. 4+ 4+
Tibialis posterior. 4+ 4+
CXR showing enlarged intercoastal spaces.
Provisional diagnosis :
Necrotising fascitis of the Left posterior back with altered sensorium secondary to septic encephalopathy?? Uremic encephalopathy??
with known case of CKD with known case of Diabetes, Hypertension .
Treatment given :
1) Inj Piptaz 2.25gm IV/ TID
2) Inj Clindamycin 600mg /IV/TID
3) Hemodialysis
4) Inj Tramadol 1ampule in 100ml NS / slow IV over 10min.
5) Tab Nodosis 500mg /PO/BD
6) Tab Orofer XT /PO/ BD
7) Tab Chymerol forte PO/TID
8) Inj HAI S/C according to GRBS.
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