Dermatology Case Study

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ADMISSION DIAGNOSES

1. Left lower leg cellulitis.

2. Left lower leg ulceration.

3. Diabetes mellitus.

4. Urinary frequency.  Rule out urinary tract infection.

5. Hypertrophy of gums.

6. Right popliteal mass.

7. Possible psoriasis.

DISCHARGE DIAGNOSES

1. Left lower leg cellulitis.

2. Left lower leg ulceration.

3. Diabetes mellitus.

4. Urinary frequency.  Rule out urinary tract infection.

5. Hypertrophy of gums.

6. Right popliteal mass.

7. Possible psoriasis.

ADMIT INFORMATION

Full history and physical have been dictated.  Briefly, this is a 48-year-old white female with obesity and diabetes who has had a smoldering left lower extremity cellulitis for the past 2 to
3 months.  It is possibly related to her pruritus and psoriasis.  She has been treated in the past with Coumadin and IV antibiotics.  On the day of admission she presented to my office with worsening of the cellulitis and a new 2-cm ulceration and was admitted for IV antibiotics and further evaluation.

ALLERGIES

ALLERGY TO PENICILLIN AND SULFA AND POSSIBLY TO COUMADIN.

Medications on admission were Procardia, Mellaril, Aldactone, Glucotrol, and hydrochlorothiazide.  The extremities revealed bilateral edema 1 to 2+ to the knees, with erythema and diffuse excoriations with erythema from the ankle to the midshin area on the left lower extremity.  She had a 2 x 2-cm superficial ulcer on the lateral aspect of the ankle.  Of note on the right popliteal fossa, she had a mobile, firm mass, 2 x 2 cm.

Laboratory on admission revealed urine with 80 to 150 wbc’s, 3 to 6 rbc’s, 10 to 15 epithelials, but only a few bacteria.  Sodium was 138.  Electrolytes were normal.  BUN and creatinine were normal.  The creatinine was 1.4, which is probably acceptable for this obese woman.  PT was slightly elevated at 15.6.  PTT was normal.  Subsequent chemistry panel was essentially normal.  CBC revealed a white blood cell count of 6, hemoglobin of 12, hematocrit of 35, with 345,000 platelets and a normal smear.

HOSPITAL COURSE BY PROBLEMS

1. Cellulitis and ulceration as well as chronic skin problems.  The patient was seen in consultation by a dermatologist who confirmed my diagnosis of cellulitis.  She was placed on IV Kefzol for 48 hours with marked improvement in her cellulitis.  Her skin condition was consistent with lichen simplex chronicus, and she was begun on Topicort cream b.i.d.  Her Coumadin was not continued as she had no venogram or Doppler evidence of deep venous thrombosis in the past.  As well, she seems to feel that the Coumadin made her rash worse.

2. Gum hypertrophy.  I felt that this was most likely periodontal disease but checked a CBC to make sure she had no evidence of leukemia with leukemic infiltrates.  The CBC was normal, and she will see her private dentist on discharge.

3. History of urinary tract infection.  The admission UA was abnormal.  I have obtained a catheterized specimen for urinary culture.  As she will be on Keflex antibiotics for the cellulitis on discharge, I will give no other antibiotics until the results of the urine culture are back.

DISCHARGE MEDICATIONS

Glyburide 2.5 mg q.d., Keflex 500 mg p.o. q.i.d., Lasix 20 mg q.d., Mellaril 50 mg q.h.s., Topicort cream to affected areas b.i.d., and normal saline dressing changes for wound care.

FOOTNOTE

Line 16 (Page 1).  Although the dictator said “as above” for the Discharge Diagnoses, it is preferable to type the diagnosis in full.

Lines 28, 29 (Page 1).  Alternative:  2-3 months.

Line 26 (Page 1).  Allergies were classified under a separate heading for clarity.

Lines 46, 47 (Page 1).  Alternative:  80-150 wbc’s, 3-6 rbc’s, 10-15 epithelials.  The slang term epis was translated as epithelials.  Alternative:  epithelial cells.

Line 1 (Page 2).  Chem panel was expanded to chemistry panel.

Line 8 (Page 2).  Alternative:  I.V.

Line 22 (Page 2).  The slang term cath was translated as catheterized.