previous history of AK amputation above 2 month before , accompanied by intermittent fever and constipation.
Patient Name:
Mr. MD
Age/Sex: 51 years/Male
CLINICAL DIAGNOSIS
– Diabetes Mellitus (DM) Type 2 for 6 years
– Infected Right Above-Knee (AK) Stump
– Grade IV Sacral Pressure Sore
– Anemia
EXAMINATION FINDINGS
– General condition: Conscious, febrile, tachycardia
– Vital Signs: – Blood Pressure: 130/60 mmHg
– Sacral Area: Grade IV Sacral Pressure Sore
INVESTIGATIONS ON ADMISSION
– Random Blood Sugar (RBS): 276 mgs%
– Blood Urea: 32 mgs% (Normal: 15-40 mgs%)
– Serum Creatinine: 1.3 mgs% (Normal: 0.8-1.0 mgs%)
– HbA1C: 7.8%
– Total Leukocyte Count (TLC): 17,400 cells/cumm (P80%, L16%, E4%)
– Hemoglobin (HB): 7.8 g% (Normal: 12-15 g%)
– USG Abdomen: Chronic Cystitis
FINAL DIAGNOSIS
– Diabetes Mellitus (DM) Type 2
– Infected Right Above-Knee (AK) Stump (History of AK amputation surgery done 2 months before)
– Grade IV Sacral Pressure Sore
– Anemia
INITIAL MANAGEMENT
– Broad-spectrum antibiotics and metronidazole were started to manage the infection.
– Insulin was administered for hyperglycemia control.
– IV fluids were provided for hydration.
– Anemia corrected by 5 units of Fresh Frozen Plasma (FFP)
SURGICAL INTERVENTION
– On day 5, Right AK Stump debridement and debridement rotation flap cover for Grade IV Sacral Pressure Sore were done under spinal anesthesia.
POSTOPERATIVE PERIOD
– On the 2nd postoperative day, wound dressing was done with drainage.
– The wound healed gradually, with significant improvement observed by the 6th and 7th postoperative days.
LABORATORY FINDINGS POST-SURGERY (6th day)
– Total Leukocyte Count (TLC): 11,100 cells/cumm
– Polymorphs: 70%
– Hemoglobin (HB): 6.7 g%
DISCHARGE CONDITION
The patient was discharged on the 17th day of admission with the following parameters:
– Fasting Blood Sugar (FBS): 140 mgs%
– Post-Prandial Blood Sugar (PPBS): 110 mgs%
The wound is healing well significantly, and the patient was stable at discharge.
MEDICATIONS ON DISCHARGE
– Insulin Injections
– Oral Antibiotics
– Wound Care: Wound dressing to be done on alternate days, with follow-up in the OPD.
IMPRESSION
PRE OPERATIVE
DURING SURGERY
POST OPERATIVE
