Italic
words and parenthesized words and sentences are for readers purpose only not to
be read when presenting a case. The letters In Blue are points of special
interest to be discussed later.
All
the patients may not have the same symptoms at presentation and the same risk
factors, so history taking should always be INDIVIDUALISED than generalized to
a standard sets of check list. It is always RECOMMENDED to ask the patient
their problems and the question associated with the problem as per the need.
Interpersonal variations are
always exists in the way the history is taken and written. Pattern, format and
style of history taking and presenting are subject to change as per
institutional protocol and region. Please kindly follow the system that is
acceptable in your context.)
A case of bilateral limb
swelling: Cellulitis
Name: Saraswoti Shrestha
Age: 44
Sex: Female
Religion: Hindu
Occupation: Farmer
Marital Status: married for 15 years
Address: Bhaktapur
Date of Admission: 21st November 2014
Date of Examination: 23rd November 2014
Mode of admission: Surgical OPD
Mrs. Saraswoti Shrestha, 44
years lady from Bhaktapur presented to surgery OPD with complains of
Chief complaints
Pain
and swelling of right leg for 11 days and left leg for 7 days
Fever
for 3 days
History of Present Illness:
According to the patient she was
in her usual state of health 11 days back then she gradually developed
localized pain over the right lower leg around 10 cm below the knee joint. The
pain was throbbing type, non-radiating. It was associated with itching
sensation. It was followed by swelling
over that area, which gradually progressed downwards towards the ankle over a
period of 3 days which made her leg swollen, red and shiny with patchy regions
in-between. Similarly, 7 days ago she
developed similar painful area in the left lower limb inner aspect and
gradually the limb swelled. The patient does not gives history of any trauma,
insect bite or walking bare foot. (Risk factor of Cellulitis) No history of rashes,
ulcer, vesicles, pus or discharge from the swollen area. No change in the color
of overlying skin. (r/o Gangrene) She is unable to weight bear due to
pain and swelling and has restricted her daily activity.
The swelling of limbs is
associated with rise in body temperature for the last 3 days which was
continuous and associated with chills. No rigor, no sweating and no rashes in
other parts of the body. However, the
temperature is not documented. The patient does not give history of travel to
other part of the country. (r/o Filaria)
Patient does not give history of
prolonged immobility or any debilitating disease. (Risk factors for DVT) No history of
severe pain even after walking a small distance. (Claudication)
The patient does not give history
of chest pain, Shortness of breath, palpitation or hemoptysis. (r/o CHF)
No history of generalized
weakness, lethargy, weight loss. No history of numbness or tingling sensation
of the limbs. No known history of decreased sensation over the hand and feet. (Peripheral Neuropathy)
No history of burning micturition,
urgency or frequency or excessive frothiness of urine. (r/o Nephrotic Syndrome)
No history of nausea, vomiting or
pain abdomen. No history of altered bowel habit. No yellowish discoloration of
skin or eyes. (r/o
Liver failure)
History
of past illness
The patient gives history of
fever with sore throat two weeks back for which she took medication from the
local medical shop which gradually subsided overtime.
She is known case of diabetes mellitus diagnoses
5 years back and is under oral medication. She does not give history of other
chronic illnesses like HTN, Epilepsy or Tuberculosis. No history of any
surgical intervention.
Personal
history
Patient does not consume
alcohol and is a nonsmoker.
She is non vegetarian and
has normal bowel and bladder habit.
She has normal sleep pattern
She has a regular menstrual
cycle occurring every 30 days, with menstrual bleeding for 2-3 days. She
changes 2-3 partially soaked pads every day. She is not using Oral
contraceptive Pills. (r/o DVT)
Family
history
He has 8 members in the
family.
No similar illness in the
family.
No chronic illness like DM,
HTN, TB or any cancers in the family.
Socioeconomic
history
She belongs to a well
sustained middle class family with good provision of clean drinking
water and
toilet facility.
Drug
and allergy history
She has been taking
medication for diabetes once daily in the morning. She does not consume other
drug for any other chronic conditions.
No known history of allergy
to any drug, food or any other substance.
Provisional Diagnosis
Bilateral Cellulitis
with k/c/o Type II Diabetes Mellitus
Differential diagnoses
Erysipelas
Deep Vein Thrombosis
Filariasis
Nephrotic /Nephritic
Syndrome
Congestive Heart
Failure
Chronic Liver disease
*** Disclaimer: This is a hypothetical
case and is not a real life scenario. However, the condition is so common and prevalent,
it is a coincidence if it matches with the life of any. This case is solely for
educational purpose with no intensions meant otherwise. ***
·
Investigations: Blood : Hb,
Coagulation profile, Serology, Blood group, Renal Fucntion test 
