Saturday, March 12, 2005

2o yo man with painful plaque

OFFICE VISIT

MARCH 07, 2005

Sam D. was seen today on a same day basis. He has a few day's history of a tender, erythematous area on the right lower leg. This is at the site of a twine ankle bracelet that he had been wearing for two years. He feels a bit run down although he has not had a fever. 

EXAMINATION: The examination shows an area of localized erythema and mild central scaling on the left lower leg just proximal to the ankle medially. It has a sharp margin. KOH prep was negative. There is definite heat at this site.  The regional inguinal lymph nodes are enlarged.

IMPRESSION: Probable cellulitis. Doubt contact. Doubt tinea.  Doubt phlebitis.

PLAN: 

1. Warm compresses. 
2. Dicloxacillin 500 mg q.i.d. 
3. Return for follow-up in four days. 

Follow-up visit March 11
S: Patient feels a bit better energy wise, but leg still red and tender.
He hasn't been able to rest - has classes, lots of responsibilities. Has not been able to do warm compresses more than twice in past 5 days.
No systemic symptoms.
O: No marked change in plaque
A: I still favor a diagnosis of cellulitis.
P: Post on ANAK VGRD for suggestions. How long should this take to resolve?
Clinically, this does not look like erythema nodosum. It began after prolonged microtrauma from a twine ankle bracelet.



20 yo man with painful plaque Posted by Hello

4 comments:

  1. There is a central clear area.
    The peripheral erythema is spreading.
    The patient is off color.
    There is micro-trauma in the centre.
    Could it be Lyme's disese - erythema chronicum migrans?
    Please check for Borrellia antibodies.

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  2. ECM: This is a good thought. In the winter, it is unusual since one needs contact with deer ticks and we are not close to deer in this season. I'll discuss this with the patient. In addition, this occured in an area that had been traumatized (hence the ? of cellulitis) Also, ECM lesions expand rapidly - not happening here. Still, I appreciate the suggestion - I would not have thought of it here. He's on doxycycline which should be good for Lyme, too - albeit he'd need more than ten days. I will keep you posted.

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  3. for cellulitis, my favourite is IV C Penicillin. occasionally when patient is not keen for admission, I use oral cefuroxime 500mg bd which is also effective.

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  4. I believe that this is most likely cellulitis due to Group A Streptococcus. The erythema is resolving slowly probably because of his size (220 lbs) causing some degree of chronic venous insufficiency and/or failure to keep leg elevated. I would suggest a compression dressing, such as an Unna boot. If you cannot apply this, then an Ace wrap tight at the ankle and less tight as it ascends to the area just below the knee. There is some data about combining antibiotics with NSAIDS or steroids to get strep cellulitis to resolve more rapidly, but I don't use them. However, they approach the concept that what you are treating now is not infection but rather the inflammatory response.

    ReplyDelete

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