Name of Patient: Adela Pascual Informant: Mel Pascual Reliability: Good Historian: Fresnido, Kyle Maffy Gabril, Gretchen

Galicia, JM Garcia, Joyce Garcia, Paul Garcia, Rayson Group: 12

Hospital: DLSHSI-UMC Department: OB-GYN Preceptor: Date Taken: July 5, 2012 Date Submitted: July 8, 2012

CLINICAL HISTORY I. GENERAL DATA A.P., 63 years old, female, widow, Roman Catholic, from Sabang, Cavite, was admitted for the first time at DLSHSI-UMC last June 2, 2012 at around 3pm.

II. CHIEF COMPLAINT namamaga yung paa as verbalized by the informant

III. HISTORY OF PRESENT ILLNESS The patient was apparently well until one month prior to admission, the patient was diagnosed with pneumonia and was given Cefuroxime tablet, Co-amoxiclav tablet and unrecalled injectible. Her pneumonia was resolved after her one-week treatment. Three weeks prior to admission, she developed edema on her feet. She went to a health center and the doctor referred her to UMC because the doctor fears that it might get infected but the patient did not comply immediately. The edema was non-pitting but it progressed rapidly and it became erythematous. She was still able to walk. Few hours before admission, the edema ascended up until the thigh. She experienced pain that was graded 10/10. The pain was described to be pulsating in character. The unresolved pain and irritability prompted her admission. IV. PAST MEDICAL HISTORY The patient was already hospitalized 3 times due to her asthma attacks. The first time was in Imus Hospital, second was in Pilar Hospital and the third was in Gen. Emilio Aguinaldo Hospital. She also had a history of pneumonia and arthritis. No history of hypertension was noted.

V. FAMILY HISTORY

The 2nd son of the patient has an allergy to dust and medicines (Alaxan Tablet). No history of kidney liver or heart diseases were noted.

VI. PERSONAL AND SOCIAL HISTORY The patient started smoking when she was 24 years old and she stopped just last year due to worsening signs and symptoms of asthma. She consumes 4-5 sticks per day. She drinks 2-3 bottles of beer but also stopped one year ago. Her husband died due to liver and lung diseases secondary to alcoholism. She used to play Majong and card games (tong-its) almost all day everyday. She lives with her 3 children and 1 son-in-law. They stay in a 2-storey house with no pets.

VII. REVIEW OF SYSTEMS General: (+) weakness, (+) weight loss, (-) loss of appetite, (-) easy fatigability Integument: (-) striae, (-) rashes, (+) erythema, (-) jaundice, (-) pallor, (-) wound Head and Neck: (+) headache, (-) dizziness, (-) lymphadenopathy Eyes: (-) redness, (+) blurring of vision, (-) pain, (-) discharge Ears: (-) otalgia, (-) disturbance in hearing Nose and Sinuses: (-) discharge, (-) rhinitis, (-) epistaxis Mouth and Throat: (-) hoarseness, (-) dysphagia, (-) toothache Respiratory: (-) cough, (+) dyspnea, (-) hemoptysis Cardiovascular: (-) angina, (-) palpitations, (-) tachycardia, (-) bradycardia GIT: (-) diarrhea, (-) constipation, (-) nausea Nervous System: (-) seizures, (-) syncope, (-) tremors Autonomic Deficiency: (-) Fecal Incontinence, (-) Urinary incontinence

PHYSICAL EXAM General Survey: The patient is fairly nourished, well developed, conscious, coherent, weak and has difficulty of breathing in lengthy sentences. She was in mild respiratory distress. She is bed-ridden and appears to be her stated chronological age of 63. Vital Signs: BP: 90/60

 RR: 20/minute PR: 80/minute Temperature: 36.2C Height: 151 cm Weight: 41 kg Skin: Upon inspection, the patient has no jaundice or pallor but has non-pitting edema in an erythematous base on her left lower extremity. The affected skin appears to be glossy. Upon palpation, the skin on the affected leg was warm and tender. There was no hyper- or hypohydrosis. Hypertrichosis was noted around the area of the mandible. No nodules or masses palpated. The nail plates are pale but do not have any deformity, clubbing, cyanosis nor lesions. No lesions in the nasal and oral mucosa. Head and Neck: The head was symmetrical with no mass, tenderness.or lymphadenopathy. Parotid and submandibular glands were not enlarged. The trachea is in the midline. The thyroid gland is not palpable and moves with deglutition.

Eyes: The eyes were symmetrical. There is even distribution of eyebrows with no masses or lesions. No edema, tenderness, or discharge were noted. On fundoscopy, the patient has positive red-orange-reflex with visible blodd vessels, macula and optic disc. There were no noted opacities but there were few small dark spots near the blood vessels on the right eye. Ears: The pinna is mobile and devoid of masses, ulcerations or tenderness. The preauricular areas have no swelling or tenderness. The canal has no hemorrhages but with cerumen. The membrane is intact with no inflammation nor hemorrhages around it. Mouth and Throat: The lips are symmetrical, dry, chapped with aphthous ulcers on the edges of her lips. Oral mucosa and gums are smooth and pink devoid of ulcerations or lesions. The palate is smooth and without lesions. The tongue is mobile. No enlargement of palatine tonsils. The uvula and palate symmetrically rises. Chest and Lungs Upon inspection, the chest was symmetrical, and rises symmetrically with respiration. There were no deformities, scars, lesions or tenderness. Upon auscultation, there were normal tracheal breath sounds. Wheezes were noted both on inspiration and expiration on both lung fields.

Cardiovascular There were no masses, pericardial bulge, thrills, heaves, or murmurs. Upon auscultation, the heart beats at a fast rate but regular rhythm. S1 is greater than S2 at the apex and S2 is greater than S1 at the base. No S3, or S4 were heard. Abdomen: The abdomen was globular. There were no visible veins, pulsations or peristalsis. No tenderness was noted. The liver span is 11 cm.

Extremities: The left leg was edematous, erythematos and with heat. The limbs were symmetrical, with no deformities, no jaundice, no edema, no clubbing,or cyanosis and onycholysis were noted. Pulses were full and symmetrical on both sides of upper and lowere extremities. Neurological Examination: I. Mental Status The patient has an appropriate behavior with a normal stream of talk. She answered questions accordingly but hesitant to disclose further details of her illness during the first interview but later on she became more cooperative in answering questions. She was oriented to time, place, and person. II. Cranial Nerves Not assessed

PATIENT ASSESSMENT DIAGNOSIS: Cellulitis secondary to Diabetes Mellitus

Basis: For Diabetes Mellitus: high FBS (+) polydipsia (+) polyuria For Cellulitis:

edema on the left lower extremity erythema tenderness in the affected area warm skin in the area of redness glossy appearance of the skin

DIFFERENTIAL DIAGNOSIS

Burn Wound Infection This infection may also present with cellulitis that manifests as erythema, induration, warmth, and tenderness in the infected area. One risk factor is also immunosuppresion. This was ruled out due to the absence of more common local signs which include conversion of a partial-thickness injury to full thickness wound and tissue necrosis. Erysipelas It is also a skin infection that is caused by Group A beta-hemolytic streptococci. It is manifested with intense erythema, induration and a well demarcated border. But this involves the lymphatics and dermis and compared to cellulitis, it is a more superficial subcutaneous infection.

Type I Necrotizing Fasciitis A skin infection that occurs as a complication of variable surgical operations or medical conditions i.e diagnostic laparoscopy, cardiac catheterization. This infection is also called polymicrobial necrotizing fasciitis that may occur after surgery. It can be linked to group A beta-hemolytic streptococci. This was ruled out because of the presence of severe pain and systemic toxicity indicating widespread tissue necrosis under a viable skin. This infection is also associated with urogenital and anogenital infections.

DISCUSSION OF THE CASE This is a case of A.P., 63 years old, female, who had edematous, warm and tender left foot 3 weeks prior to admission. She had a history of asthma and pneumonia. Her edema ascended to the thigh which prompted her consult. Upon admission, her FBS showed abnormally high value and consequently diagnosed with Diabetes Mellitus. Celllulitis is an infection of the skin commonly caused by bacteria. This can be attributed to several factors mainly the invasion of the bacteria into a broken or normal skin down to the soft tissues. This results to an infection and inflammation. The inflammation would manifest as erythema, tenderness, warmth and swelling of the skin. Risk factors may include injury or trauma to the skin, ulcers from certain diseases including diabetes mellitus and vascular diseases, and use of corticosteroids or medications that suppress the immune system. Cellulitis does not only manifest to people with broken skin, but it also occurs to people who are immunocompromised. This includes those who have Diabetes mellitus, people taking corticosteroids and even alcoholics who have increased risk of cellulitis and tend to get worse infections. The common problem of most patients with diabetes is foot infection. This is attributed to the compromised vascular supply that gives poor and inefficient circulation in the lower extremities. Local trauma and/or pressure give rise to the infection. The impaired microvascular circulation limits the phagocytes to access the infected area. Complications may include a severe and extensive chronic soft tissue and bone infection that causes a foul exudate. Also, peripheral vascular resistance may arise and can cause gangrene.

MANAGEMENT: For the Cellulitis: Give beta-lactam antibiotics to the patient. Initial treatment would be via the intravenous route. Local care involves the elevation and immobilization of the infected limb. For the Diabetes: administer insulin; strict diet For asthma: continue maintenance drugs

REFERECES: http://emedicine.medscape.com/article/237378-overview http://chealth.canoe.ca/channel_condition_info_details.asp?disease_id=145&channel_id=14 3&relation_id=1711 http://www.emedicinehealth.com/cellulitis/article_em.htm