CASE WRITE-UP - CELLULITIS

I will start up some post regarding some of my orthopedic case write up that i have done during my university years. This will be good for medical students to learn the formats on how to take history from patients and how to conduct the relevant physical examination on orthopedic related cases.


CELLULITIS

Case History: Lower Limb [Cold Case]

Personal Profile:

Name: Mr A
Age: 52 years
Sex: Male
Address: Melaka.
Occupation: School security guard
Date of admission: 19th April 2008
Date of examination: 21st April 2008
Hospital No: 417276

Chief Complaints:

Pain at the right leg for 7 days.
Swelling at the right leg for 3 days.

History of Presenting Illness:

Patient was apparently asymptomatic 7 days ago when he suddenly developed pain at the right leg which was sudden in onset, more at the distal 1/3rd of his leg, initially moderate in intensity then it progressively increased.  It became severe since 2 days ago. The pain was pricking in nature. The pain is aggrevated upon walking. There are no relieving factors. There is no radiation of pain.

Patient also had diffuse swelling which started 3 days ago at the right leg. Initially it was a mild swelling and it progressively worsened. The swelling started at the distal 1/3rd of the leg and progressively increased till the mid third of the leg. There was also redness of skin around on the anterior side the right leg, from the distal 1/3rd of the leg extending till mid third of the leg.

Patient also had fever for 3 days, which was sudden in onset, moderate grade, and intermittent. There was no aggravating or relieving factors.

Patient was able to bear weight and walk on his right leg. Patient seeked treatment for this at a local clinic and was given analgesics and paracetamol. The pain was not reduced upon medication.

Patient apparently had a fall in front of his house 10 days back, when he was carrying a pot he hit a brick with his left leg and fell to the ground. Patient sustained abrasions on his right leg at the medial side just about 3 cm above the medial maleolus. Patient did not seeked any form of treatment at that time. There is no other injuries sustained

  There is no deformity, no stiffening of joints, no shortening of the limb, no loss of sensation at the distal part of the leg.



Past History:
Patient was diagnosed with diabetes mellitus on admission.
No other significant past history, no past history of allergy to any drugs.

Family History:
No significant past family history.

Personal History:
Patient is a smoker. he smokes about 10 sticks/day for the past 10 years (5 pack years). His appetite is normal, bowel and bladder habits are normal, there are no sleep disturbances. Patient does not consume alcohol. There is no history of drug abuse.


Working Diagnosis:


1) Cellulitis of the anterior compartment of the right leg.
           Reason : There is pain and swelling. The redness is of spreading type indicating
spreading type of inflammation of the affected area. There is history of   trauma.

2) Osteomyelitis of right tibia.
Reason : There is injury of the right leg, pain and swelling of the right leg. There
    is also history of fever.


General Examination:

Patient is conscious, co-operative, well built, and appears to be obese
(BMI is 46). Patient is in supine position. There is pitting edema of the right leg till the mid third of the leg. There is no pallor, no icterus, no central or peripheral cyanosis, and no finger clubbing.

 Vital Signs: 
Blood pressure: 126/82 mmHg
Pulse: 75 beats /min, normal volume and regular rhythm. No vessel wall
           thickening.
Respiratory Rate: 21 /min
Temperature: 37 ºC

Cardiovascular Examination:

S1, S2 heard, no murmurs heard.

Respiratory Examination:

Vesicular breathing heard with no added sounds.

Abdominal Examination:

No abdominal tenderness, no organomegaly.

There is no decrease in bowel sounds.

Local Examination:

Inspection:

Attitude – 

Left

Hip : neutral

Knee : neutral

Ankle : neutral 

There is redness seen from the upper third to the lower third of the right leg in the anterior and medial compartment. Dry, scaly, and blackish discolouration of the skin on the dorsum of the right foot and also just above the ankle joint. There is no deformity or apparent shortening, no visible sinuses seen. There is a swelling in the right leg, extending from the lower third to the upper third of the right leg, which is diffuse. On the left leg, there was no swelling, redness, scar, sinuses, deformity or shortening seen.

Palpation:

There is a local rise of temperature at the site of swelling (at the lower third to the upper third of the right leg). Maximum tenderness present throughout the right leg. On the left leg there was no rise of temperature or tenderness present.

Peripheral pulses ( Dorsalis pedis artery and posterior tibial artery ) is felt and no coldness of the skin distal to the swelling. 

Movements:

Movements    Right                            Left

                Active        Passive  Active    Passive

Knee joint

Flexion Restricted Restricted 0 - 130 º 0 - 130 º

Extension Restricted Restricted 0 0

Ankle joint

Dorsiflexion 0 – 10º 0 – 10º 0 - 30 º 0 -30 º

Plantar flexion 0 – 10º 0 – 10º 0 - 45 º 0 -45 º

Measurements:

Measurement                                                                        Right          Left

Apparent length (xiphisternum to medial malleolus)               125.5 cm    125.5cm

True length (anterior superior iliac spine to medial malleolus) 88 cm        88 cm

Femur length (anterior superior iliac spine to medial joint line) 56cm 56cm

Tibial length (medial joint line to medial malleolus)                 32cm 32cm

Distal neurological Examination :

There is no distal neurological deficit. Full range of movements of toes present and there is no loss of sensation of the lower limbs.

Distal vascular Examination :

There is no distal vascular deficit. Dorsalis pedis artery could be felt  and there is no distal limb coldness and capillary feeling time is less than 3 seconds on both lower limbs.

Provisional Diagnosis:

1)      Cellulitis of anterior and medial compartment of the right leg.

   Reason: There are presence of tenderness, pitting edema and the affected part

   has rise of temperature indicating an inflammatory condition. There was also  

   history of trauma leading to abrasion at the affected site. There is no stiffening

   or deformity of joint present.

Investigations:

Plain radiograph of the leg with the knee and ankle joint both AP and lateral view

Findings: There are no abnormal findings. X ray appeared normal.

ESR : 77mmol/hr

Fasting blood sugar : 9.1 mmol/L

 

X-Ray finding : There is soft tissue swelling, with no other abnormalities seen.

Final Diagnosis:

• Cellulitis of anterior and medial compartment of the right leg.

Reason: There are presence of tenderness, pitting edema and the affected part

has rise of temperature indicating an inflammatory condition. There was  

also history of trauma leading to abrasion at the affected site. There is no

stiffening or deformity of joint present.