Individual out put of case presentation

SEKH RABIUL
Group 30

GENERAL DATA
V.C.L a 18 YO, Female, Filipino, Roman Catholic, born on 07/21/2005, working in a call centre,
residing in Cebu City came in for admission for the first time to VSMMC on 05/25/2024 at 10.55 AM
INFORMANT: Patient and mother via message
RELIABILITY : 80%

CHIEF COMPLAINT: Painful bump on buttocks

HISTORY OF PRESENT ILLNESS

3 Days PTA, patient experienced onset of pain on right gluteal region with a pain score of 4/10,sharp,
non radiating, persistent, not aggravated nor relieved by other factors. No other associated
symptoms such as erythema, itching and fever. No consultation done, no medications taken.
Condition tolerated.
2 days PTA, persistence of symptoms now with a pain score of 10/10, radiating to the back, left
gluteal region and groin. associated with erythema and itching. Not associated with limitation of
movement and fever. Patient medicated with 2 tablets of Amoxicillin of unrecalled dosage, noted
temporary relief for 1-2 hours.
Hours PTA, worsening of symptoms, unable to sit due to the pain prompted to seek consult and was
subsequently admitted.

PAST MEDICAL HISTORY

2018- Hospitalised at tertiary private hospital and was diagnosed with DM Type 1, admitted for 1
week for DKA with maintenance of Insulin Lispro 100 units/ml BID (* ask about follow ups with
endocrinologist)
January, 2024- ER Consult at VSMMC due to swelling in gums unrivalled diagnosis. No past surgeries
No known food and drug allergies

PRENATAL HISTORY
Born to a 18 YO ( G1P0) mother. First prenatal check up was at 4 weeks AOG at the Local Health
Centre. Prenatal vitamins included ferrous sulphate, folic acid, calcium and multivitamins. .
Laboratories were unremarkable. No known maternal illness as claimed by the mother. Non-smoker,
non alcoholic beverage drinker, denies illicit drug use.
NATAL HISTORY
Born live, term, female neonate delivered via normal spontaneous vaginal delivery at home by a
midwife, birthweight 2500 g APGAR and Ballard score- unrecalled . No complications during birth as
claimed

POSTNATAL HISTORY
Exclusively breastfed from birth upto 6 months old. Semi solid foods were introduced at 6 months.
Solid foods introduced at 1 year old.

IMMUNISATION HISTORY
Complete for age at Local Heath Centre as claimed * Ask for the vaccination card to verify.
* Ask for adolescent vaccines taken
COVID 19 vaccine- 2 doses + booster

FAMILY HISTORY
Maternal - (+) DM (-) HPN (-) BA (-) Thyroid disease Paternal -(+) DM (_) HPN (-) BA (-) Thyroid disease

PERSONAL AND SOCIAL HISTORY

The birth rank of the patient is 1/1. Mother, 39 YO is a OFW. Father, 49 YO, is a mechanic. Household
members are 2- the father and the patient. House is made up of wood and concrete, well ventilated.
Drinking water is mineral. Garbage disposal is everyday. Patient works as a call centre agent and
works on the compute for 8 hours/day. Usual diet is hotdogs and junk foods.

HEADSSS ASSESSMENT

HOME
• Patient lives with her father in Cebu City as her mother is an overseas worker (*ask since when is
mother working abroad)
• Patient has a good relationship with her parents but does not share her problems with her parents.
• Patient says she wants her mother to come back home and stay with them

EDUCATION AND EMPLOYMENT

• Patient quit studying. (* ask which grade and the reason)
• Patient claims she never failed any grade.
• Patient claims she has never been expelled from school.
• Patient has faced bullying at school because of her looks. (* ask bout how did she cope with it)
• Currently works at call centre. (* ask at what age did she start working, how many hours a week)
• Patient claims to have good relations with her work colleagues, even better relations compared
with her parents.
• Patient currently has no future plans. (* ask why no plans for the future )
EATING
• Patient eats 3 times a day.
• Usual diet - prefers to eat hotdogs, eats 3-4 everyday, other than that she eats pork and rice
with some veggies
• Patient’s body shape causes her some stress. (* ask about how she deals with it)
• She tries to get in better shape by exercising. (* ask how many times a week )
• No history of intentional weight loss through purging, binge eating

ACTIVITY
• Patient does not participate in any sports activity.
• Patient claims she exercises once to twice a week.
• Patient’s favourite thing to do in her free time is to watch TV Dramas.
• Patient uses facebook, Instagram and tiktok.
• She claims her screen time is 5-6 hours.

DRUGS
• Patient denies any illicit drug use.
• Patient drinks alcohol twice a month, she prefers drinking whiskey 6 shots and beer 5 glasses.(*
apply CRAFT)
• Patient smokes vape.

SEXUALITY
• Patient identifies as female.
• Patient is interested in men and is currently in a romantic relationship with a 24y/o man. ( * ask
at what age did she start dating, and age of man at that time)
• She has had a total of 3 sexual partners.
• She uses protection like condoms for sexual intercourse. (* ask about the history of STI)
• She claims she has never been forced to do any intimate acts.

SUICIDE
• Patient has some stress related to work and life because of which she feels depressed.(*ask about
how she deals with it )
• She attempted suicide last year by cutting her wrist, due to some personal problems. (* ask about
the reason and administer GAD, PHQ 9 and CSSR)

SAFETY
• wears a seatbelt and helmet
• feels safe and secure at home (* ask about feeling secure in community and workplace) • not a
member of a fraternity or gang
• never been in a fight
• never carried a weapon

PHYSICAL EXAMINATION:
●General survey: Patient was examined awake, alert and not in respiratory distress:
Vital Signs:
BP: 120/80 mmHg
Temp: 37.0 °C
HR: 120bpm
RR: 23 cpm
O2 Sat: 99% on room aid
● Anthropometrics:
● Ht: 155 cm
● Wt: 52 kg
● 21.6 BMI

Skin: warm, good skin turgor and mobility, (-)pallor, (-) jaundice, erythematous non blanched dry
rashes in right gluteal regions extending to inter gluteal cleft with presence of plaques. HEENT:
●Head: normocephalic, symmetrical
●Eyes: pink palpebral conjunctiva, anicteric sclerae
●Ears: mobile pinna without masses or tenderness
●Nose and Sinuses: patent nares, (-) nasal discharge, (-) nasal congestion, nasal septum is
midline (-)alar flaring
●Mouth and Throat: (+) multiple tooth loss, (-) gum bleeding, (-) oral ulcers, non enlarged or
non-inflamed tonsils
●Neck: no cervical lymphadenopathy, no palpable thyroid mass
Chest and Lungs: Inspection: (-)deformities (-) subcostal/ intercostal retractions (+)tachypenic.
Palpation: equal chest expansion for both anterior and posterior,(-) tenderness, equal tactile fermitus
Percussion: resonant on all fields
Auscultation: (-) rales and (-) wheezes Clear breath sounds
Cardiovascular: Distinct heart sounds, (+)tachycardia, regular rhythm,(-) pulsating suprasternal
notch,(-) dilated neck veins ,(-) sweating, PMI at 5th ics on mid clavicle line,(-) heave,(-)thrills,()
(-)murmur.
Abdomen: flat, normoactive bowel sounds, soft, non-tender, no palpable masses,
(-)hepatomegaly,(-)splenomegaly.
Musculoskeletal- (-)kyphosis,(-)lordosis(-)scoliosis,(-) joint pain,(-)muscle pain Extremities:
strong pulses, CRT < 2 secs, (-) deformity,()edema,(-)clubbing.
●Hematological- (-)pallor, (-) bleeding tendency, (-)easy bruising
GU- (+) erythematous rash extending from perineum to vaginal region, grossly female, (-)hernias,
tanner stage III

●Neurologic Exam:
● GCS- 15
CN I Olfactory —Smell coffee
CN II Optic — Visual acuity not tested, visual field normal
CN III, IV, VI— Oculomotor, Trochlear, Abducens ,Pupils equally round and reactive to light and
accommodation, intact Eyes when opened looked straight ahead which means oculomotor pathways
are intact
Trochlear and abducens intact
CN V Trigeminal— Able to sense the touch on the face Able to firmly clench the teeth CN VI VII Facial:
—Able to smile, close eyes, & wrinkle forehead.Able to taste
CN VIII Vestibulocochlear/ acoustic— Able to hear and respond
CN IX, XGlossopharyngeal & Vagus —Able to swallow ! (+)gag reflex
CN XI Spinal Accessory — able to shrug shoulders, even with resistance
CN XII Hypoglossal —Tongue symmetrical, middle and movable at all sides, intact
Cerebellar— Able to perform nose-to-nose test
Motor— 5/5 on all extremities
Sensory—Intact

ADMITTING DIAGNOSIS:
1. Pressure ulcer, sacral region, Grade-1
2. Diabetes mellitus type-Poorly Controlled
3. Late adolescent with psychosocial issues

DIFFERENTIAL DIAGNOSIS:
INTERTRIGO:
Intertrigo is a common inflammatory skin condition that is caused by skin-to-skin friction (rubbing)
that is intensified by heat and moisture.

Rule-in
Itchy
Painful
Erythematous
Mostly affected at groin/at skin rubs together/traps wet Diabetes

Rule out
No foul smelling
No crusted appearance

INVERSE PSORIASIS:
Inverse psoriasis is an immune-mediated condition. It causes a rash in areas of your skin that rub
together, including your groin and armpits.

Rule-in
Itchy
Erythematous rash
Bump
Painful
Commonly in skin fold areas such as groin

Rule out
No purple patches
Pain occur in centre of plaques
No fissures found

ERYSIPELAS:
Acute, non-necrotising infection of upper dermis, superficial lymphatics; usually unilateral,Well-
defined demarcation between normal, infected tissue; non-purulent
Usually caused by streptococci; most often Streptococcus progenies

Rule in.
Swollen and shiny Erythematous
Poorly controlled diabetes Painful
Itchy

Rule out
Fever
Chills
Headache
Nausea and vomiting
Blister
Lesions on the leg , face fingers, toes

ABORATORIES:
CBC Result
WBC 14.80 H
RBC 4.39
Hgb 129
Hct 38.70

Differential Count Result

Neutrophils 79.110 H
Lymphocytes 13.00 L
Monocytes 6.190
Eosinophils 1.220 L

Platelet. 421 H

FINAL DIAGNOSIS:
1.Pressure ulcer, sacral region, Grade-1
2.Diabetes mellitus type-l: Poorly Controlled
3.Late adolescent with psychosocial issues

CASE DISCUSSION:
1.Pressure Ulcers:
• Localized skin, underlying-tissue injury, caused by unrelieved pressure/pressure in combination
with friction, shearing forces
• Blood flow diminishes
• Pressure → ischemia → necrosis
• Bony prominences most commonly affected like
Sacrum, heels, hips, elbows.

RISK FACTORS:
• Reduced mobility
• Chronic/acute disease (e.g. hip fracture, stroke,
Parkinson disease)
• Central/peripheral neural damage, altered level
of consciousness, advanced age
• Reduced perfusion
• Atherosclerosis, peripheral vascular disease,
hypotension, smoking
• Factors affecting skin structure
• Malnutrition, protein deficiency, skin moisture
(incontinence, sweating)
• Diabetes mellitus

DIAGNOSTICS:
LAB RESULTS
o Swab culture
o May help determine treatment in healing-resistant
ulcers

TREATMENT:
MEDICATIONS
• Topical sulfadiazine cream

OTHER INTERVENTIONS
• Debridement of biofilm, dressing replacement,
negative pressure therapy
Prevention:
o If bedridden, reposition at least every two hours (reduces chance of ulcer development)
o Use of special mattresses

2.DIABETES MELLITUS:
• Diabetes mellitus is a chronic condition where tissue cells can't properly absorb and use glucose,
so it stays and builds up in the blood.
• Normally, pancreatic islet beta cells produce insulin, which acts on insulin receptors on tissue cells
to promote uptake and storage of glucose, amino acids, and triglycerides, as well as stimulate
glycolysis, protein synthesis, and lipogenesis.
• There are two types of diabetes, type 1 and type 2.
o In type 1 diabetes, there's autoimmune destruction of the pancreatic islet beta cells, resulting in
severe insulin deficiency and, ultimately, hyperglycemia.
o This is in contrast to type 2 diabetes mellitus, where the pancreatic islet beta cells stop properly
responding to stimulation to produce insulin, combined with insulin resistance, meaning that the
tissue cells aren't able to appropriately respond to the little insulin that's still being produced.
• In either disease type, the resulting hyperglycemia can cause clinical manifestations ranging from
prediabetes and diabetes mellitus, to severe life-threatening conditions, like diabetic ketoacidosis, or
DKA, most commonly seen in patients with type 1 diabetes, and, hyperosmolar hyperglycemic state,
or HHS, most commonly in type 2 diabetes.

DIAGNOSTICS: LAB RESULTS

Urinalysis
• Albuminuria, glycosuria
Blood tests
o 1 Non-fasting/fasting glucose tests
o THbALC
o Diabetic ketoacidosis (DKA)
o Glucose > 250mg/dL
o Hyperosmolar hyperglycemic state (HHS) o Glucose >600mg/dL
OTHER DIAGNOSTICS
Physical examination
o Fundoscopic exam
o Cotton wools spots, flare hemorrhages o Monofilament testing
o I sensation
o Lower extremities
o I pedal pulses, presence of ulcers

TREATMENT:
MEDICATIONS
o Diabetes mellitus type |
o Insulin
o Diabetes mellitus type II
o Oral antidiabetic agents, insulin

OTHER INTERVENTIONS
o Metabolism regulation with diet
o Weight loss, exercise
o Smoking cessation