Transcript GENERAL DATA

GENERAL DATA
• E.M.
– 42 years old, female, single
– Filipino, Roman Catholic
– San Pablo City, Laguna
– Informant: patient
– Reliability: 85%
CHIEF COMPLAINT:
NON-HEALING ULCER ON THE
LEFT LEG
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
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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
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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
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
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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.
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
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Menarche: 13 years old
Menstrual flow- interval: 28- 30 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
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(+) 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
PHYSICAL EXAMINATION
• 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
• Flabby abdomen, normoactive bowel sounds,
tympanitic on percussion, soft, no mass, no
tenderness, no murphy’s sign, liver span 9cm