Anemia and renal failure secondary to ? Multiple Myeloma, AKI secondary to left lower limb cellulitis / ? Multiple myeloma, Recurrent cellulitis secondary to ? cutaneous vasculitis/amyloidosis ,k/c/o htn and denovo DM 2

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A 67 YEAR old male came with c/o left lower limb swelling since 10 days , fever since 10 days ,SOB on exertion since 3 days 

HOPI:

Patient was apparently asymptomatic 5 yrs back,on routine investigation diagnosed as hypertensive (on medication tab. amlo 5mg ) and had b/l knee pains since 4 yrs back underwent knee replacement- 3 yrs back had developed Left limb swelling and serous discharge for which he underwent debridement and fasciotomy. Patient was taken to pulse hospital-stay for 1 month (creat : 5.8 to 3.8). Since 1 month c/o right ear pain .

On 27 th jan patient c/o lower limb swelling- sudden onset , gradually progressive to current state, aggrevated on walking ,relieved on rest and limb elevation , swelling associated with pain which is insidious in onset , non progressive, intermittent aching type ,aggrevated with movements, relieved. with medications.

Fever since 10 days intermittent,high grade associated with chills and rigor .

SOB - Insidious onset, gradually progressive from grade 1 to 2 since 3 days ,no orthopnea/pnd.

No h/o burning sensation of urine , decrease urine output.

Past h/o: 

Hypertension since 5 yrs not on regular medication (amlo- 5mg, aten-50 mg)

Diabetes- denovo 2 days ,not on any medication,

Surgery- B/Lknee replacement

No h/o BA,TB,CVA 

Addictions: smoking- 1 to 2 cigarettes/day since 20 years, stopped 1 month back

General examination:

pallor -++

oedema of feet + left lower limb

on local examination- oedema of left LL + involving foot ,ankle and leg 

Tiny ulcers + largest  1x1 cm over Posterior aspect of leg, multiple patches of skin loss +,mild local erythema+, tenderness+ , pitting edema + , peripheral pulses +

On 11/2/22

On 14/2/22

 on 15/2/22

No cyanosis, icterus, clubbing, lymphadenopathy.

Vitals: temp:afebrile, PR :106bpm,RR: 18 cpm, spo2 : 98@ ra , BP:120/80 MMHG, GRBS : 134 mg/dl

CVS: S1S2+ ,JVP raised

RS: BAE+

CNS: NAD

PROVISIONAL DIAGNOSIS: AKI 2° TO LEFT LOWER LIMB CELLULITIS ,CKD 2° TO ANALGESIC NEPHROPATHY

 H/O HTN WITH DENOVO - DM 

 ANAEMIA UNDER EVALUATION ? MULTIPLE MYELOMA

 RIGHT EAR PAIN UNDER EVALUATION  

On  27/12/21

Treatment: on day 1

1.IVF- NS,RL at uo+30 ml/hr

2. Inj . Clindamycin 600 mg iv BD 

3. Inj. Piptaz 2.25 gm iv/TID

4. Inj pantop 40 mg iv OD

5. Inj zofer 4 mg iv sos

Surgery refferal

AMC BED 8 SOAP NOTES ON 12/2/22

S: decreased SOB

O: BP:130/90 mmHg

PR:90 bpm

RR:23 cpm 

SPO2: 95% RA

RS:BAE+

CVS: S1S2 + ,JVP increased

P/A:Obese,bs+

CNS:NAD

I/O:3100/2250

Grbs: yesterday

@8am-119,@2 pm- 138,@ 8pm-117,  today @8am-151

A: AKI SECONDARY TO LEFT LOWER LIMB CELLULITIS ,CKD SECONDARY TO ? ANALGESIC NEPHROPATHY 

H/o HTN ( not on regular medication) ,denovo DM2

ANAEMIA UNDER EVALUATION ? MULTIPLE MYELOMA

P:Monitor vitals 4 hrly

1.IVF-NS,RL at uo+30 ml/hr

2. Inj . Clindamycin 600 mg iv BD 

3. Inj. Piptaz 2.25 gm iv/TID

4. Inj pantop 40 mg iv OD

5. Inj zofer 4 mg iv sos

Ortho and ENT referral

On 14/2/22 AMC BED 8 -67y/M

S: decreased SOB

O: BP:130/90 mmHg

PR:90 bpm

RR:23 cpm 

SPO2: 95% RA

RS:BAE+

CVS: S1S2 + ,JVP increased

P/A:Obese,bs+

CNS:NAD

I/O:2300/1900

Grbs: 200 mg/dl

A: 1) Anemia and renal failure secondary to ? Multiple Myeloma

2) AKI secondary to left lower limb cellulitis / ? Multiple myeloma

3) Recurrent cellulitis secondary to ? cutaneous vasculitis/amyloidosis 

4) k/c/o htn and denovo DM 2

P: Inj.PIPTAZ 2.25 gm iv TID

Inj.CLINDAMYCIN 600 mg iv BD

CIPLOX EAR DROPS 3/3/3- RE

Ivf ns , rl at uo +30 ml/hr

Inj.lasix 40mg iv /bd 

Monitor vitals 4 hrly

This patient has 1)anemia.

(Peripheral smear showing microcytosis ,spherocytes , Target cells , rouleax formation)

2) Renal failure

3) Hypercalcaemia (corrected calcium - 11.4 mg/dl)

4) Gamma gap - (TP-7.3;alb-2.54 ; globulin-5)

So Multiple myeloma can be a possibility . 

Pathology are willing to do bone marrow biopsy

His recurrent cellulitis can also be due to cutaneous myeloma/amyloidosis.

Serum electrophoresis was sent .

  soap notes on 16/2/22

AMC BED 8 -67y/M

S: decreased SOB,C/o pain in left lower limb

O: BP:110/90 mmHg

PR:90 bpm

RR:23 cpm 

SPO2: 97% RA

RS:BAE+

CVS: S1S2 + 

P/A:Obese,bs+

CNS:NAD

I/O:1900/1250

Grbs: yesterday @8am-108, @2pm- 102,@8pm-96

today@8am -98

A: 1) Anemia and renal failure secondary to ? Multiple Myeloma

2) AKI secondary to left lower limb cellulitis / ? Multiple myeloma

3) Recurrent cellulitis secondary to ? cutaneous vasculitis/amyloidosis 

4) k/c/o htn and denovo DM 2,b/l knee replacement done 4 yrs back

5)Mass in the right external ear 

6)left knee synovitis

P: inj. MEROPENEM 1 gm iv /bd( day 2)

TAB.ultracet po/qid

CIPLOX EAR DROPS 3/3/3- RE

Ivf ns0.45 with 1 amp optineuron,rl at uo +30 ml/hr

inj HAI S/c 2u---2u--2u

Inj.lasix 40mg iv /bd 

Monitor vitals 4 hrly

frequent change of posture,left  lower limb elevation

YESTERDAY BONE MARROW ASPIRATION WAS DONE, REPORT AWAITING.