88 year old female referred by GP to Emergency Department for general decline from past 2 weeks. She has decreased oral intake. She has completed course of oral Cephalexin as per her General practitioner.
Diagnosis– Cellulitis
Hypernatraemia
Oral Candidiasis
Dehydration
Allergies– Penicillin
Past Medical History– Dementia
Hypertension
Diverticulitis
Asthma
UTIs
GORD
Bowel Cancer
Chronia Pain- Neck, Shoulder and Knee
SCC- Leg
She is incontinent. Bed Bound- lifting machine to be used for tranfers.
Medications- Metoclopramide
Paracetamol
Bricancyl (QID)
Antacid
Vitamin D
Pantaprazole
Temazepam
Frusemide
Tapentadol
Budesonide
Norspan – Weekly
Assessment-
Alert, GCS 14, Confused. The pupils were equal and reactive to light. Mild weakness in both legs. There was normal strength in upper limbs.
Afebrile, temperature- 35.5
Blood pressure- 148/89 mmHg, Respiratory rate- 18 bpm, SPO2 98% on room air, BGL- 5.9.
Chest Clear
Abdo- Lax, Non- tender, No nausea or vomiting reported by patient.
Skin was warm, clean and intact.
Bilateral swollen legs
Both lower legs- Hot and tender/ red.
- L) Thigh Lymphangitis