59year old male with lower limb cellulitis

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Case presentation:

A 59 year old male patient who is shopkeeper by occupation came with chief complaints of

bilateral lower limb swelling since 2months,

Ulceration over right leg since 2months

Ulceration over left leg since 10days

Swelling of upper limbs since 10days

Abdominal distension since 10days

Patient was apparently asymptomatic 2months ago, after which he developed swelling of both lower limbs up-to knee, patient then noticed small blebs over posterior aspect of right leg and over the dorsum of the foot, which grew in size, burst and with green discharge and ulceration for which he received conservative treatment at a local government hospital.

Abdominal distension is gradual in onset and progressive in nature associated with pain in right hypochondriac region it is associated with nausea and decreased urine output since three days

Patient noticed increase in swelling of the left lower limb with blebs 10days back for which patient underwent fasciotomy at local hospital along anterior medial, anterier lateral and lateral aspect of the left lower limb.patient received antibiotics after the procedure, he c/o decreased appetite since 10days associated with constipation. Patient also has bilateral upper limb swelling since 2days

H/o joint pains since 5years associated with morning stiffness

H/o tingling of b/l lower limbs on and off

Past history:

He is a k/c/o HTN since 14years and is on regular medication Levisac-H OD( olmesartan 20mg and hydrochlorothiazide 12.5mg)

K/c/o DM since 14 years and is on regular medication Glime-m (glimeperide1mg and metformin 500mg) OD before meal

K/c/o hypothyroidism for which he taking thyronorm 50mcg since 5years

K/c/o rheumatoid arthritis since 5years and is on deflazocort 6mg OD since 5years

Not a k/c/o epilepsy, TB, asthma, CVA

No similar complaints in the past

Personal history :

diet vegetarian with decreased appetite, sleep adequate,with altered bowel movements(contipated) and regular bladder movements ,nonalcoholic and nonsmoker.

General examination

Patient is conscious, coherent and cooperative

No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy.

Edema is present

Vitals

Patient is afebrile,

PR-80bpm

Bp - 120/60mmHg recorded in right arm supine position

RR- 24cpm

Systemic examination :

P/A - on inspection all the quadrants are moving equally with respiration, no dilated or engorged veins, no scars or sinuses

Abdominal distention present

Hernial orifices intact

On palpation abdomen is soft, nontender and there is no organomegaly

Free fluid and shifting dullness present

CVS: S1,S2 present no murmurs

CNS : NAD

RS :Trachea central, BAE+, Normal vesicular breath sounds are heard, no added sounds

Local examination

Right lower limb

Pitting edema up-to knee level with local rise of temperature, ulceration over postreo-lateral , medial aspect of leg and dorsum of the foot

Peripheral pulses are present

Tenderness +, granulation tissue +

Left lower limb

Pitting edema up-to knee level, local raise of temperature and tenderness present, slough +, peripheral pulses felt, granulation tissue+, ulcer over the anterior medial aspect(7*2cms) ant-lateral aspect (6*2cms) and lateral aspect(9*3cms) of the leg ,dorsum of the foot (2*3cms)