Dermatology Case Study

CONSULTATION

The patient is an elderly, pleasant female who is quite cooperative.  She was admitted to the hospital because of cellulitis of the right lower extremity.  There has been blistering of the area on the dorsum of the foot as well as higher up towards the ankle.  She has redness extending all the way up to the mid-pretibial area.  There is no history of lymphadenopathy, and judging from the chart, she has been afebrile.  She was started, after finding out that her white count was abnormal, on Cefobid and tobramycin and infectious disease consultation sought.

PHYSICAL EXAMINATION

Exam today shows a temperature of 37 degrees Centigrade, a blood pressure of 130/70, a respiratory rate of 20, and pulse rate of 80. General appearance:  An elderly female in no acute distress.

Head and ENT:  Grossly negative. Neck:  Supple. Lungs:  Clear and resonant. Heart:  Grade 1 systolic murmur; otherwise negative.

Abdomen:  Scars of surgery.  The abdomen is not obese but protruding.  She has some left lower quadrant discomfort that is mild. Vaginal and rectal:  Not done. Lymph nodes:  No enlargement. Exam of the extremities reveals blistering cellulitis over the dorsum of the foot with swelling and extension of the abnormal coloration to the mid-pretibial area.  The foot appears warmer than the other.

After sterile preparation the 2 blisters were aspirated, 0.2 cc of fluid was taken out, and this was sent for Gram stain and culture.

IMPRESSION

Probable streptococcus cellulitis.

DISCUSSION

The patient has had a Gram stain done yesterday, and it does show gram-positive cocci.  This may well be staph, but I think we should give her penicillin till the culture reports are out.  The blistering is typical of strep.  I would go ahead and give her
2 million q.6h. of the penicillin and modify therapy according to culture report.

I thank you for allowing me to participate in the care of this pleasant, elderly female and will reassess p.r.n.

FOOTNOTE

Line 42.  The brief form strep was expanded to streptococcus in the Impression.