CC
Follow up elevated blood pressures.
Follow up vertigo.
New spot on left leg.
S
The patient is a 64-year-old female who was noted to have elevated blood pressures. She had been on atenolol in the past, but got some hair thinning with it. She was willing to try it again, from her physical appointment in April 2015. This time however, she felt very fatigued and groggy on it. We, therefore, switched her to losartan 50 mg, which she was taking a half a tablet per day. With taking this, however, she states she started feeling more anxious and had more difficult time sleeping. She stopped it on her own. She has been checking her blood pressures at home and they have ranged in the 120's/60s to 80s.
The patient was seen on June 1, 2015 secondary to vertigo. These symptoms did resolve completely.
The patient does state she has a lesion on her left calf that gets red and scaly. Sometimes it is there and sometimes it looks like it is almost gone away. It does not bleed.
Objective
Vital Signs
Blood pressure 122/68. Pulse is 66. Respiratory is 124.
General
The patient is alert,
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There is no pigment associated with it.
A/P
Elevated blood pressure, blood pressures at home, however, have been excellent. She has had side effects on both atenolol as well as losartan. Given that her blood pressures are so well controlled at home and it is good today, we will hold on starting her on any blood pressure medications. She will continue to monitor her blood pressure.
Left calf skin lesion, likely actinic keratosis versus seborrheic keratosis. This was treated with a liquid nitrogen x2 treatments today. I did discuss this might be some scarring, if the lesion, does come back it will need to be rechecked, it might blister. We discussed care of it. If this is the case, this could lead to infection. The patient demonstrated understanding of all of
The patient was referred for a new itchy and tender bilateral groin lesions that the patient says will drain pus. He also has multiple other complaints. He gives a history of being allergic to DOXYCYCLINE. As previously stated, he has tender sites which can drain pus off and on in his groin for years. There is also history of facial acne and scalp acne since his late teens. He took Accutane during his 20s with improvement by history. He flared and repeated Accutane about one year after completing the first course by his history. He is bathing with unscented Dove and uses cocoa butter lotion. He also has a second problem of itching over his back, shoulders, and arms, and legs
Patient states that she has had no head injuries, past or present. Patient states she has never suffered from vertigo or dizziness. BB states that she rarely suffers from generalized headaches. Patient avoids taking pain relievers of any kind when she does present with head pain.
PAST MEDICAL/SURGICAL HISTORY: As above. SOCIAL HISTORY: Status post heavy smoking, 50+-pack-year history. He quit 10 years ago. Status post alcohol abuse, quit 3 or 4 years ago. He lives by himself and no longer drives but has 2 daughters here in Miami who take him where he needs to go. FAMILY HISTORY: Patient’s wife died 14 years ago of COPD due to lifelong smoking. Brother has diabetes mellitus. Unremarkable family history otherwise. REVIEW OF SYSTEMS: No fever, no nausea, no vomiting. Patient has incontinence of bowel. No shortness of breath, no chest pain, no palpitations. PHYSICAL EXAMINATION: Well-developed, well-nourished white male who is alert and oriented x3. Wears bilateral hearing aids. Afebrile with blood pressure 130/70. NECK: No carotid bruits. LUNGS: Clear to auscultation bilaterally. HEART: S1, S2 normal. No murmur. No S3 or S4. ABDOMEN: Soft, nontender. No arterial bruits. No masses, no organomegaly. EXTREMITIES: No edema. No pulses present in the lower extremities. The right great toe is absent. The left great toe shows a 2 x 1 cm deep ulcer with redness around the toe with pus extruding. PLAN 1. Get consult with Dr. Beth Brian, Infectious Disease. 2. Follow up with Dr. Hirsch, Orthopedics. (Continued)
In 1958 Alfred Hitchcock released what is considered the greatest film of all time, Vertigo. Vertigo is a film noir thriller that stars James Stewart and Kim Novak. Stewart's character, Scottie Ferguson, is sent to follow and investigate his old friend’s wife, Madeline. He spies on her strange actions and at the time falls deeply in love with her. The viewer is given a restricted narrative through the eyes of former detective, who suffers from vertigo, as he follows Madeline through San Francisco. The audience views the film from the same perspective as Scottie. Hitchcock pompously puts the viewer into Scottie’s eyes in scenes where he is following Madeline give Scottie a voyeuristic sense. The narrative is later switched to unrestricted as
Patient is a 9 year old adolescent male, presents with a 2 day history of itching encrusted sores especially around the mouth area. Parent is using OTC antibiotic ointment with no improvement, no recent history of fever. Parent states that pat recently visited a petting zoo
She converses appropriately. Blood pressure 92/60 supine. Blood pressure decreased to 72/50 standing. Pulse is 90 and regular. Weight 113 pounds. She has a normal appearance of her face and does not have a masked appearance of her face. She has good strength throughout her face. She has good strength of her extremities. She has only minimal cogwheel rigidity at the left wrist, but no cogwheel rigidity at the right wrist. She has no tremor of her hands. She moves her extremities freely and with normal speed. She is able to rise on her own from a sitting to a standing position, only minimal bradykinesia of standing. She walks fairly freely and there is a normal cadence of her gait. She did not have dyskinetic movements of her extremities. She is able to walk, including turning without losing her balance. She does not shuffle her feet when walking. She does not have en bloc turning. She has good posture stability
On Exam: BP today was 140/86. Head and neck exam was all clear. She had no oral or nasal ulcers. She had no lymphadenopathy or bruits. Heart sounds were normal and the chest seemed clear, as did the abdominal exam. Musculoskeletal exam disclosed widespread Heberden's and Bouchard's nodes. She had no swelling or stress pain at the MCPs. She was not tender at the CMC joints. She had no swelling in the wrist, elbows or shoulders. She had no soft tissue tender points. She has bilateral knee crepitus but only slight instability and no effusions. She had actually good range of movement of both hips. She was tender in the lumber spine and has a scar at the lower lumbar spine from her previous operations. Her feet are somewhat flat with tenderness across the
Patient denies history of skin disease. Reports two serious sun burns while swimming and not re-applying sun screen. Reports occasional dryness of skin during the winter. Denies any
Upon assessment, I found that both her lower legs had +1 edema, were red, skin was a bit peeling, and warm to touch. She reported a bit of tenderness on palpation. The right leg, however, had black “scabs” towards the outer side; upon palpation, I noticed that they were under the skin and I could not feel any bumps. Other than her lower legs, her skin was dry and intact, color consistent with her ethnicity, no surgical incisions, and mucous membranes were pink, moist, and intact. She had a #22 IV in her left hand, and the IV site was clean. She was oriented x3, calm and cooperative, had clear speech, had no weakness, no flaccid tone, and no numbness. Her strength was normal in upper extremity, and her lower extremities moved against resistance. Her pupils were round, equal in size, and reactive to light. Her blood pressure was 133/76, heart rate 94, oxygen saturation of 98% on room air, respiratory rate of 18, oral temperature of 36.7
Mr. Lewis is seen for Dr. Craane at Oak Park Heights. Mr. Lewis is a 74-year-old gentleman with multiple medical problems, including rheumatoid arthritis, hepatitis C, diabetes mellitus, hypertension, and severe respiratory insufficiency. His recent history is well known to us as he was originally at Faribault when he became ill with the current episode of leg ulcerations. He was being treated for rheumatoid arthritis and severe COPD at that time and had significant edema in his legs. He was being treated with methotrexate for his rheumatoid arthritis and was also on low dose prednisone at that time. He developed very, very painful leg lesions that quickly developed from darkened skin lesions to undermined ulcerations that had a gangrenous
Blood pressure -138/88, HR 71, Lung sounds –clear, temperature 98.8 F, radial pulse and pedal pulses +1 bi-laterally, normoactive bowel sounds. No history of smoking, drugs, alcohol use or diabetes; takes no daily medications. Surgical history: Hernia surgery September 2016 and cataract surgery September 2013. Moderately active, walks every day, sometime incorporating hand weights. Patient presents with minimal trembling unilaterally, (left side) when fingers stretched out, reports movements have been slower than normal. Patient’s wife reports “He’s been eating more slowly and it has been taking longer for him to get dressed in the morning.”. Upon examination it was determined that patient has reduced arm swing, slight stiffness in neck, difficulty rising from sitting position in the chair, masked facial features and deteriorated balance. No signs or symptoms of stroke.
The father decided to do the biopsy and they took her back. Studdert removed an inch long ellipse of skin and tissue stretching from the top of the foot to the tendon. Then, he removed some of the muscles at the center of the redness. Both samples were sent to the pathology department where a dermatopathologist had later confirmed their suspicions. When she was taken into surgery, the destruction was obvious and they had questioned the need for an AKA or BKA. However, they decided to trust their guts again and did a debridement and flushed out the muscles. Two hours later, she was transported to another hospital and put in a hyperbaric oxygen chamber for two hours to boost muscle repair. The following day, she was taken back into surgery to remove more of the infected muscle and they decided to increase the oxygen treatment to twice a day for two hours. Twelve days later, she was released from the hospital bacteria free. A patch of skin, about sixty-four-square-inches, had been removed from her thigh and used as a skin
Then there is generalized erythema rapidly followed by the development of flaccid blisters and desquamation, as seen in this patient. The mucous membranes are not involved, which is also consistent with our patient. The surrounding areas of her face were involved, but the mucous membranes were spared. This condition is also associated with a positive Nikolsky sign. A Nikolsky sign is the ability to extend the area of superficial sloughing by applying gentle lateral pressure on the surface of the skin at an apparently uninvolved site. This was found incidentally in our patient when the adhesive tape of an IV line was removed resulting in sloughing off of the skin below it. Furthermore, due to the sloughing off of skin with pressure, there tends to be increased desquamation in areas of mechanical stress like the flexural areas, buttocks, hands, and feet. If SSSS is suspected, cultures should be obtained from the blood, the urine, the nasopharynx, the perianal area, and any other abnormal skin or suspected focus of infection. The intact bullae are sterile and will come back without growth. In this patient, blood cultures had no growth to date and the pan-cultures from the mouth, nares, eyes, and anus were non-specific. Diagnosis for SSSS is usually clinical, although it may be confirmed with skin biopsy that shows a cleavage plane in the lower stratum
PHYSICAL EXAM: The leg itself looks good with minimal to no swelling. He has absolutely no calf pain to palpation and no pretibial edema. The ankle is just a little bit stiff. Dorsiflexion is to about zero. Plantar flexion is better. All wounds are healed at this point.
Even though she was treated with her initial symptoms, her pain, stiffness and swelling of the hands continued and 1 month later both knees became similarly affected and after six months of the initial presentation, she developed two subcutaneous