Medicine II Infectious Diseases BGD 1

1. Medicine IIInfectious DiseasesBGD 1 Subsection B1

2. 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%

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

4. History of Present Illness • 4 years PTA • 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

5. History of Present Illness 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

6. 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

7. 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 • 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

8. History of Present Illness 3 1/2 years PTA • 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.

9. 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.

10. History of Present Illness History of Present Illness 2 years PTA • 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.

11. History of Present Illness History of Present Illness 1 1/2 months PTA • 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.

12. History of Present Illness History of Present Illness 18 days PTA • 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

13. History of Present Illness 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

14. 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

15. Review of Systems 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

16. Past Medical History 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

17. OB History OB History nulligravid

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

19. Sexual History Sexual History the patient denies any sexual contact

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

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

22. 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

23. (+) 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.

24. Physical Examination • Pale palpebral conjunctiva, anicteric sclera • Moist buccal mucosa, no oral ulcers, anictericfrenulum 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

25. Physical Examination • Adynamicprecordium, 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

26. 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

27. SALIENT FEATURES Subjective 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 • 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

28. Assessment PyodermaGangrenosum with superimposed infection r/o TB of the skin