Medicine II Infectious Diseases BGD 1 Subsection B1 1

E.M. –42 years old, female, single –Filipino, Roman Catholic –San Pablo City, Laguna –Date of admission: 11/18/09 –Informant: patient –Reliability: 85% E.M. –42 years old, female, single –Filipino, Roman Catholic –San Pablo City, Laguna –Date of admission: 11/18/09 –Informant: patient –Reliability: 85% 2

Chief Complaint: non-healing ulcer on the left leg 3

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

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 History of Present Illness 5

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 History of Present Illness 6

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 History of Present Illness 7

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 8

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 9

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 10

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 11

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 12

History of Present Illness rapid increase in size of the wound increase in the severity of the pain now grade 10/10 ADMISSIONADMISSION 3 days PTA History of Present Illness 13

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 14

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 15

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 16

OB History nulligravid OB History 17

Menstrual History M- 13 years old I days D- 3 days A-2 ppd moderately soaked S- dysmenorrhea Day 1 Menstrual History 18

Sexual History the patient denies any sexual contact Sexual History 19

Personal and Social History Non-smoker Non-alcoholic beverage drinker No diet preferences Personal & Social History 20

Family History (+) CVD mother, died at 76 years old (+) sibling MI (-) skin disease (-) DM (-) asthma (-) allergies (-) thyroid diseases (-) autoimmune disorders Family History 21

Physical Examination 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 22

(+) 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. 23

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 Physical Examination 24

Adynamic precordium, AB at 5 th 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 Physical Examination 25

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 26

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 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 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 27

AssessmentAssessment 28