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Medicine IIInfectious Diseases

BGD 1Subsection B1

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General Data

• E.M.– 42 years old, female, single– Filipino, Roman Catholic– San Pablo City, Laguna

– Date of admission: 11/18/09– Informant: patient– Reliability: 85%

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Chief Complaint:

non-healing ulcer on the left leg

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History of Present Illness

• Pain, swelling over the area of the right Achilles tendon

• Consult: San Pablo Medical Center

• Ancillary: X-ray of the right leg – normal

• Management: unrecalled patch medications which provided relief of the pain, but persistence of the swelling

4 YEARS PTA

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History of Present Illness

• persistence of the swelling

• Consult to a “manghihilot”

• Massage therapy was done

• undocumented fever temporarily relieved by intake of Paracetamol 500mg tab

4 YEARS PTA

History of Present Illness

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• persistence of the swelling and fever

• Confined at San Pablo Medical Center

• Assessment: abscess of the right foot

• Patient was given unrecalled antibiotics.

• Discharged with cast applied over the right leg

4 YEARS PTA

History of Present Illness

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• After 7 days, patient noted heaviness of the right leg with pus dripping from the cast

• Consult - Removal of the cast

• Multiple ulcers on the right leg

• Wound debridement was done.

• Increase depth of the ulcer, skin graft from right thigh was harvested and was place over the area

• Wound had good coaptation and was completely healed

4 YEARS PTA

History of Present Illness

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• patient noted appearance of the same lesions over the of the wound

• Consult: Philippine General Hospital

• Biopsy: TB of the skin

• Medications: Anti-TB for 6 months

• After the therapy, the wound was noted to be completely healed.

3 1/2 years PTA

History of Present Illness

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• patient noted recurrence

• Consult: RITM

• Assessment: TB of the skin

• Advised transfer to another hospital

• San Pablo Medical Center

• Above the knee amputation of the right leg with skin graft from the left thigh was done.

2 1/2 years PTA

History of Present Illness

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History of Present Illness

• New ulcer was noted on the medial aspect and dorsum of the left leg and right forearm

• Advised cleansing with bleach

• Healing of the wound with granulation tissue.

2 years PTA

History of Present Illness

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History of Present Illness

• Painful nodules on the anterior aspect of the left leg erythematous patch several moist ulcers over the dorsum and medial aspect of the left leg

• Cleanse with bleach and would heal with granulation tissue.

• Consult: PGH

• Ancillary: Venous duplex scan was requested – normal results

• Assessment: not disclosed.

1 1/2 months PTA

History of Present Illness

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History of Present Illness

• Recurrence of several painful nodules grade 8/10 on the anterior leg erythematous patch ulcers that coalesce with necrotic tissues and oozing with blood eventually affecting the posterior aspect of the left leg.

• self-medicated with Tramadol, Biogesic and Diclofenac which provided temporary relief of the pain

18 days PTA

History of Present Illness

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History of Present Illness

• rapid increase in size of the wound

• increase in the severity of the pain now grade 10/10

ADMISSION

3 days PTA

History of Present Illness

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Review of Systems

• General: (-) weight loss (-) fever, (-) excessive sweating, (-) weakness, (-) easy fatigability, (-) insomnia

• Skin: (-) itchiness, no photosensitivity, (-) hair changes• Eyes: (-) blurring of vision, (-) itchiness, (-) pain• Ear: (-) deafness, (-) discharge, (-) tinnitus• Nose: (-) epistaxis, (-) colds, (-) discharge• Throat: (-) soreness, (-) tonsillitis• Mouth: (-) sores, (-) fissures, (-) bleeding gums• Neck: (-) stiffness, (-) limitation of movement, (-) masses• Vascular: (-) intermittent claudication

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Review of Systems• Pulmonary: (-)dyspnea , (-) no cough, (-) hemoptysis• Cardiac: (-) chest pains,(-) palpitations, (-) PND,• Gastrointestinal: (-) diarrhea, (-) constipation (-) change in

bowel movements• Genitourinary: (-) frequency, (-) flank pain, (-) gross

hematuria• Muscular: (-) joint swelling, (-) bone pains• Endocrine: (-) nocturia, (-) polydipsia, (-) polyphagia, (-)

polyuria (-) paresthesia, (-) heat-cold intolerance• Hematopoetic: (-) abnormal bleeding (-) easy bruisibility• Neurologic: (-) seizures • Psychiatric: (-) anxiety, (-) depression, (-) interpersonal

relationship difficulties

Review of Systems

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Past Medical History• (+) Blood transfusion, number of units

unrecalled when the patient underwent above the knee amputation (2007)

• (-) Hypertension • (-) allergies • (-) asthma• (-) thyroid diseases• (-) DM• (-) skin disease

Past Medical History

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OB History

• nulligravid

OB History

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Menstrual History

• M- 13 years old• I-28- 30 days• D- 3 days• A-2 ppd moderately soaked• S- dysmenorrhea Day 1

Menstrual History

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Sexual History

• the patient denies any sexual contact

Sexual History

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Personal and Social History

• Non-smoker• Non-alcoholic beverage drinker• No diet preferences

Personal & Social History

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Family History

• (+) CVD mother, died at 76 years old • (+) sibling MI• (-) skin disease• (-) DM• (-) asthma• (-) allergies• (-) thyroid diseases• (-) autoimmune disorders

Family History

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Physical Examination

• Conscious, coherent, ill-looking, wheel chair borne not in cardiorespiratory distress

• BP: 120/80mmHg on both upper extremities and left lower extremity, PR 100 bpm, full, regular, RR 20 cpm, regular, T=37.0°C

• Wt 120lbs (54.54 kg) Ht 5’2 (157.48cm) BMI 22

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• (+) well defined ulcer on the entire left leg with purplish irregular border topped with bleeding necrotic tissue with slightly violaceous plaque topped with multiple punch out ulcer some with crusts on the right forearm, dorsum and medial aspect of left foot and right AKA stump, (+) scars over the right and left thigh.

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• Pale palpebral conjunctiva, anicteric sclera• Moist buccal mucosa, no oral ulcers, anicteric

frenulum lingua.

• Neck is not rigid, thyroid gland is not enlarged, no palpable cervical lymph nodes

• Symmetrical chest expansion, no retractions, resonant on percussion, no crackles, clear breath sounds unimpaired vocal and tactile fremitii

Physical Examination

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• Adynamic precordium, AB at 5th LICS AAL, s1>s2 at the apex, s1<s2 at the base, no heaves, no lifts, no thrills, no murmurs

• Flabby abdomen, normoactive bowel sounds, liver span 9cm MCL, tympanitic on percussion, soft, no mass, no tenderness, no murphy’s sign

• Pulses full and equal, no cyanosis, no edema

Physical Examination

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Neurologic Examination

• Conscious, coherent, oriented to three spheres, GCS 15

• Cranial Nerves:– pupils 2-3mm ERTL– (+) corneal reflex– (+) ROR, clear disc margins, no

visual field cuts– EOM full and equal– V1V2V3 intact– no ptosis– can smile, can raise eye brows,

can puff cheeks– gross hearing intact– uvula midline on phonation

– (+) gag reflex– can shrug shoulders– turns head side to side against

resistance• tongue midline on protrusion

• Motor: MMT 5/5 on the LLE and UE

• Sensory: no sensory deficits• DTR’s: +2 on LLE, and UE. • No Babinski• No nuchal rigidity

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SALIENT FEATURES

Subjective

• Nulligravid• Non-healing rapidly

progressing ulcer on the left foot

• Not known diabetic• (-) polyuria, polyphagia,

nocturia, no weight loss• Non-smoker• (-) changes in bowel

movement• (-) joint pains, (-) morning

stiffness• (+) above the knee

amputation right lower extremity

Objective• 42 y/o, Female• BP 120/80mmHg on both upper

extremities and left extremity, PR 100 bpm, full, regular, RR 20 cpm, regular, T=37.0°C

• Warm dry skin, (+) well defined ulcer on the entire left leg with purplish irregular border topped with bleeding necrotic tissue with slightly violaceous plaque topped with multiple punch out ulcer some with crusts on the right forearm, dorsum and medial aspect of left foot and right AKA stump, (+) scars over the right and left thigh.

• Pale palpebral conjunctiva, Pulses full and equal, no cyanosis, no edema

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Assessment

Pyoderma Gangrenosum with superimposed infection r/o TB of the skin