Long case

presentation
Saadia Rehman
(1502-mbbs-038)
History:
Patient profile:
� Name: Mushtaq Wali
� Age: 43 yrs
� Gender: male
� Residence: scheme 3 RWP
� Marital status: Married
� Admitted on: 25-7-2019
� Admitted through: OPD
 Presenting complaint:

� Wound on left gluteal region for

last 40 days.
History of presenting complaint:

My patient was alright 40 days back when he had

an intramuscular injection at left gluteal region for
his complaint of headache that resulted in blisters
and abcess formation at that site. After 3days, he
went to central hospital ,RWP. where he was
admitted and underwent debridement and was
given antibiotics after which the wound increased
progressively to include left lateral side of thigh.
Cont.
He has ℅ pain which is so severe that
he is unable to lie ,sit or walk. He has
history of purulent discharge from wound
.He has also ℅ fever and vomiting
5episode/day which he has experienced
after debridement.the vomitus contains
food particles andit was projectile
,relieved by taking medicine.
He was referred to Plastic surgeon and
then to AL-Nafees hospital for proper
treatment.
 Past medical history:
● he has history of hepatitis C 2yrs back for
which he has taken treatment .
Past surgical history:
� cataract surgery 4 yrs back
� admitted for debridement and dressings
many times
 Systemic inquiry:
� CNS: There is history of headache and
dizziness.
� CVS: There is no history of dyspnea,
orthopnea, PND and palpitations.
� RES: There is no history of cough, chest pain.
� GIT: There is history of vomiting 5 episode
/day .
 Contt…
� UG: There is no history of increased urinary
frequency , nocturia, burning micturation,
dysuria and hematuria.
� MSK: not significant
� Endo: There is no history of heat intolerance
or cold intolerance.
Family history:
� No history of diabetes mellitus,
hypertension, hepatitis, asthma,
tuberculosis and cancer.
Allergy history:
� Not significant
Drug history:
❏ Cap. doxacycline 100mg
❏ Tab. linezolid 800mg
Personal history:
He is a non-smoker
Socio-economic history:

o Belongs to low socioeconomic status.

Examination:
 General appearance:
� A conscious man sitting on bed
uncomfortably and well oriented in time,
place and person.
 Vitals:
� Temperature: Afebrile
� Pulse:80 bpm; regular and of good
volume
� Blood pressure: 120/80 mmHg
� Respiratory rate: 16 per min
� Oxygen saturation: 98%
General physical examination:
� Hands: There is no muscle
wasting;clubbing,koilonychia,leuconychia
, splinter hemmorrhages and pallor.
� Eyes: There is no jaundice or pallor.
� Neck lymph nodes are not palpable.
� JVP not raised.
� No pedal edema.
LOCAL EXAMINATION
There is an ulcer present on left gluteal
region extending from gluteal cleft to
lateral border of thigh,measuring
approximately 30*15cm , elliptical in
shape , edges are sloping at one side
and punched -out at other side with
regular margins , floor contains
granulation tissue and subcutaneous fat.
LOCAL EXAMINATION
Base is of gluteus maximus muscle ,
surrounding skin is normal, there is severe
tenderness but no temprature difference.
Arterial examination: dorsalis pedis ,posterior
tibial and popliteal artery was palpable on
both legs.
Nervous system examination sensory and
motor system intact.
Lymph nodes examination inguinal lymph
nodes not palpable
 Respiratory system
examination:
On inspection:
� Respiratory rate= 16 bpm.
� No scar mark, visible pulsations
On palpation:
� Trachea is palpable.
� Chest expansion= 3.5cm, apex beat is located
at 5th ICS in MCL, vocal fremitus = N
On percussion:
� resonant.
On auscultation:
� Normal vesicular breathing.
Cardiovascular system
examination
On inspection:
� No chest deformity
On palpation:
� Apex beat in 5th ICS in MCL.
On auscultation:
1st and 2nd heart sound is audible. No added
sound
Abdominal examination
On inspection:
� No scar mark, visible pulsations
� Type of respiration is abdominothoracic.
On palpation:
� Soft and non tender abdomen.
� No mass is palpated.
� No hepatosplenomegaly.
On percussion:
� Resonant.
On auscultation:
� Bowel sounds = present.
Central nervous system
examination

� GCS = 15/15
Differential diagnosis
� Necrotising Fasciitis
� Iatrogenic soft tissue infection
� Cellulitis
� pyoderma gangrenosum
� gas gangrene
� superficial abcess
Provisional Diagnosis
NECROTISING FACIITIS
INVESTIGATIONS:
� Blood complete picture
� Liver function tests
� Renal function tests
� Urine R/E
� Culture and sensitivity
� Hepatitis b/c serology
Management
MANAGEMENT
Medical Management
❏ Analgesics
❏ Antibiotics

❏ high dose penicillin G

❏ Broad spectrum Antibiotics

(third generation cephalosporins and

metronidazole)
❏ Antiemetics
Surgical MANAGEMENT
❏ Wound debridement and dressing
regularly
❏ Skin grafting