GENERAL DATA E.M. – 42 years old, female, single – Filipino, Roman Catholic – San Pablo City, Laguna – Informant: patient – Reliability: 85%

NON-HEALING ULCER ON THE LEFT LEG CHIEF COMPLAINT:

HISTORY OF PRESENT ILLNESS 4 years PTA crampy, intermittent pain over the posterior part of the right foot grade 10/10 lasts for a minute and spontaneously swollen, warm and tender to touch Consult: San Pablo Medical Center Ancillary: X-ray of the right leg – normal Management: unrecalled patch medications which provided relief of the pain, but there was persistence of the swelling

HISTORY OF PRESENT ILLNESS 4 years PTA Persistence of the swelling Consult to a “manghihilot” Massage therapy was done undocumented fever temporarily relieved by intake of Paracetamol 500mg tab every 4 hours

HISTORY OF PRESENT ILLNESS 4 years PTA 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 4 years PTA After 7 days, patient noted heaviness of the right leg with pus dripping from the cast  consult Removal of the cast revealed ulcerating wound over approximately 4x4 cm in size oozing with pus Wound debridement was done. Skin graft from right thigh was harvested and was placed over the wound Wound had good coaptation and was completely healed

HISTORY OF PRESENT ILLNESS 3 1/2 years PTA Patient noted recurrence of the wound over the same area Consult: Philippine General Hospital Biopsy: TB of the skin Medications: Anti-Koch’s for 6 months (patient was compliant) After the therapy, the wound was noted to be completely healed.

HISTORY OF PRESENT ILLNESS 2 1/2 years PTA 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.

HISTORY OF PRESENT ILLNESS During the interim, the patient was apparently well and was asymptomatic. She noted complete healing of her above the knee stump and the harvest site of the graft.

HISTORY OF PRESENT ILLNESS 1 ½ months PTA patient noted ulcerative lesions over the right forearm and medial aspect and dorsum of the left foot. Consulted :PGH advised Zonrox + PNSS solution to wash the wounds three times a day dried up the wounds and noted slight resolution of the wounds

HISTORY OF PRESENT ILLNESS 1 month PTA patient noted swelling over the left knee noted another wound developed over the dorsum of the left foot accompanied by pain grade 8/10 Self-medicated: Tramadol, Biogesic and Diclofenac which provided temporary relief

HISTORY OF PRESENT ILLNESS 3 days PTA rapid increase in size of the wound increase in the severity of the pain now grade 10/10 Admission

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

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

PAST MEDICAL HISTORY (+) Blood transfusion, number of units unrecalled when the patient underwent above the knee amputation (2007) Unrecalled childhood immunizations (-) Hypertension (-) allergies (-) asthma (-) thyroid diseases (-) DM (-) skin disease

OB HISTORY nulligravid

MENSTRUAL HISTORY Menarche: 13 years old Menstrual flow- interval: days Duration: 3 days Amount: 2 ppd, moderately soaked dysmenorrhea usually Day 1

SEXUAL HISTORY the patient denies any sexual contact

PERSONAL AND SOCIAL HISTORY Non-smoker Non-alcoholic beverage drinker No diet preferences

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

PHYSICAL EXAMINATION Conscious, coherent, ill-looking, wheel chair borne not in cardiorespiratory distress Palpatory BP 100 mmHg, Auscultatory BP 100/80mmHg 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

Warm dry skin (+) multiple weeping ulcer over the left leg (+) ulcer over the right forearam with dry areas topped with crusts over the right forearm and right AKA stump (+) scars over the right and left thigh PHYSICAL EXAMINATION

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