FACULTY OF MEDICINE

DERMATOLOGY POSTING
CASE WRITE-UP
PATIENT DETAILS

NAME : MRS X
AGE : 65
GENDER : FEMALE
RACE : INDIAN
OCCUPATION : GROCERY SHOP OWNER
MARITAL STATUS : MARRIED
ADDRESS : KB KELANTAN

CHIEF COMPLAINT
Multiple hyperpigmented palpable skin lesions at bilateral legs for 6 months
HISTORY OF PRESENT ILLNESS
- A 65 years old Indian lady with underlying diabetes mellitus on diet control,
hypertension, bronchial asthma presented to dermatology clinic with a chief complaint of
multiple palpable hyperpigmented skin lesions at both of the legs below knee region.
- Patient claimed that initially there was small whitish spots at the both of the legs below
knee region then it became itchy and blackish.
- Patient mentioned that there are some hyperpigmented skin lesions at her back and wrist
regions as well.
- Patient claimed that she had intermittent fever.
- Patient claimed that there was no serous, blood or pus discharge from those lesions.

PAST MEDICAL HISTORY

- Patient has Diabetes mellitus under diet control
- Patient has hypertension
- Patient was diagnosed with bronchial asthma 20 years ago and on medications

DRUG HISTORY
- T Perindopril 5mg
- T Montelukast 10mg
- Salmeterol 1 puff
- Salbutamol 2 puffs

ALLERGY HISTORY
- No significant history of allergies
FAMILY HISTORY
- There’s no other significant family history
- There is no malignancy history in the family

SUMMARY
- A 65 years old Indian lady with underlying diabetes mellitus, hypertension, and bronchial
asthma presented to dermatology department with a chief complaint of multiple palpable
hyperpigmented skin lesions at both of the legs below knee region.

PHYSICAL EXAMINATION FINDINGS

- On examination, the patient is alert, conscious, not tachypnoeic, talk in full sentences, had
warm peripheries and capillary refill time less than 2 seconds.
- Vital signs BP : 138/84
PR : 76
RR : 28
T : 37.3
SPO2 : 100 % under room air

- Lungs clear, equal air entry

- CVS – dual rhythm no murmur
- Abdomen – soft and non-tender
- Bilateral pedal oedema up to midshin
- No lymph node palpable
- There are some small skin patches on the right and left anterior wrist

IMPRESSION:
1. Bilateral multiple hyperpigmented skin lesions

PLAN:
1. Medication is given
2. Follow up