45 year old male with gas gangrene and hypokalemia

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

 A 45 year old male resident of cherlapally farmer by occupation came with chief complaints of severe pain in the right upper limb since 10 days and discharge from the shoulder region.

Hopi:

Patient was admitted in the hospital on 23 rd November 

In the general surgery department for pain and discharge from the right shoulder and diagnosed to have gas gangrene. He was treated accordingly by giving incision and drainage and antibiotics . Later the patient was referred to general medicine department as a the patient has metabolic acidosis, electrolyte imbalance , Severe Hypokalaemia and Hypotension.

Past history:

Patient was apparently asymptomatic 2 years back he came to the hospital because of increased urine output ,then he was diagnosed to have diabetes at our hospital since then he was on oral hypoglyemic drugs after 6 months his medication was changed to insulin. 

History of weight loss since 2 years.

August ,2022

He came to the hospital with fever and slurring of speech and was diagnosed to have urosepsis and treated accordingly and discharged.

October,2022

He came with SOB ,decreased urinary output,

Diagnosed to have Acute kidney injury and he underwent 4 sessions of dialysis and was discharged.

Daily routine before illness 3 months ago :

Wake up in the morning by 4am then he will have milk by 5am and then he eat food (rice)by8am and then he goes for cattle rearing come back by 3pm then he takes some food rest and then he takes food at 6pm and goes to sleep by 7pm.

After illness he cannot go to to work, he cannot walk for even short duration because of breathlessness . Severe pain in the arm restricts his daily activities.

Personal history

Diet:mixed 

Appetite: increased

Sleep: adequate 

Bowel (loose stools)and bladder(irregular)

Addictions: Alcohol since 25 yrs (180ml/day)

FAMILY HISTORY:No significant family history

DRUG HISTORY:No history of allergy to any drugs 

GENERAL EXAMINATION

Patient was conscious coherent and cooperative

Poorly  built and nourished  

Pallor present

No Icterus

No cyanosis

No clubbing

No generalized lymphadenopathy

Bilateral pedal edema (pitting) present

Vitals 

Temp Afebrile 

PR70  bpm

BP 130/70 mm Hg 

RR 16 cpm

GRBS 102mg/dl 

SYSTEMIC EXAMINATION

Respiratory System

Inspection

Symmetrical chest seen

No scars and sinuses 

Trachea central

Palpation:

Inspectory findings are confirmed

Percussion: 

Resonant note present over all lung areas

Ascultation:

Normal vesicular Breath sounds heard. 

PER ABDOMEN 

Inspection: 

No Abdominal distension 

No scars, sinuses, mass visible 

Umbilicus is inverted

Palpation:

Inspectory findings are confirmed 

No local rise of temperature

Tenderness absent

Auscultation

: Normal bowel sounds heard

No bruit heard

CARDIOVASCULAR SYSTEM EXAMINATION 

Inspection : Bilaterally symmetrical chest present 

No scars, sinuses

Palpation:

Inspectory findings are confirmed

Apex beat normal

On Auscultation : 

S1 S2 heard

No murmurs or additional heart sounds

CENTRAL NERVOUS SYSTEM EXAMINATION 

No focal neurological defecits  .

Investigations : 

On 23 rd November :

ECG:

1-12-2022

ECG 

PROVISIONAL DIAGNOSIS 

Right upper limb gas gangrene (post op) with hypokalemia 

TREATMENT 

On 1/12/2022

I.MVT 500 ml OD IV

I.meropenem IV BD 

I.Clindamycin IV TID 

I.Astymin IV BD 

Tab Pantop 40 mg peroral OD 

T.Nodosis500 PO OD 

.T.Chymoral peroral OD 

T.Dolo 650 PO OD 

Syrup.Potklor PO OD 

Protein Powder in 1 glass of water

T.Orofer PO OD 

T.VTIC PO OD