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CASE PRESENTATION
Mark Dale G.Cruz
By:
Cruz, Mark
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GENERAL DATA:
M.A., 13 year old female, single, Roman Catholic,Filipino,from Bian, Laguna, consulted for the firsttime at San Vicente Health Center on September 16,2010.
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CHIEF COMPLAINT:
itchiness
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HISTORY OF PRESENT ILLNESS:
3 month PTC, patient experienced a gradual onset ofitchiness described as severe and worst at time. This
was associated with papular rashes in the axillae,around the waistline, and on the buttocks. No consult
was done. However, medication was applied to theaffected area in the form of Sulfur soap appliedeveryday. There was no relief.
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1 week PTC, symptoms persisted, but this time it wasassociated with a single nodule (0.5 cm in diameter)on the lateral aspect of the right foot which wasintensely itchy. This was also associated with
undocumented fever described as on and off,moderate, with no medications given.
1 day PTC, symptoms persisted, and the nodule had
significantly increased in size (1 cm.). This promptedthe consult.
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PAST MEDICAL HISTORY:
(-) HPN
(-) DM
(-) CANCER(-)ASTHMA
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FAMILY HISTORY:
(+) HPN- Mother
(+) Asthma-Mother
(+) COPD-Father(-) DM
(-) CA
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PERSONAL/SOCIAL HISTORY:
Non-smoker
Occasional alcoholic beverage drinker
Allergic to eggs and fishNo known allergies to drugs
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REVIEW OF SYSTEMS:
General: (-)weight loss, (-)fatigue
Skin: (+)pruritus, (+)papules (+)1 cm. nodule on
lateral aspect of right foot
HEENT: (-)headache, (-)dizziness,
(-)nausea, (-)blurring of vision, (-) discharge,
(-)ear pain, (-)tinnitus,(-)epistaxis, (-)hoarseness, (-)dysphagia,
(-)odynophagia
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Neck: (-)pain, (-) stiffness
Respiratory: (-)hemoptysis, (-)dyspnea
Cardiovascular: (-)clubbing, (-)edema,
(-)pallor, (-)palpitations, (-)cyanosis
GIT: (-)abdominal fullness, (-)loss of appetite,
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GUT: (-)frequency, nocturia, dysuria, hematuria,
urgency, flank pain
Endocrine: (-) heat/cold intolerance, polyuria,
polydipsia
Musculoskeletal: (-)claudication, leg cramps,
muscle/joint pains
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PHYSICAL EXAM:
General: Patient is conscious, coherent, not incardiorespiratory distress
Vital Signs: BP= 100/70 Temp= 36.8
PR= 84 RR= 22
Skin: (+)papuler rashes on axillae, around thewaistline, and the buttocks, red to brown, in wavy lines,scattered (+)1 cm.nodule on lateral aspect of right foot
warm to touch
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HEENT: Scalp without lesions, pink palpebralconjunctivae, anicteric sclerae, ears symmetric, acuitygood to whisphered voice, oral mucosa pink withoutlesions, tongue midline, intact TMJ, trachea midline, no
palpable mass and tenderness, (-) CLADS
HEART: Adynamic precordium, normal rate, regular
rhythm, , apex beat is at the 5th ICS MCL, (-) carotidbruits, (-)thrills, (-)heaves, (-)murmurs
LUNGS: Thorax is symmetric with no deformities,
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ABDOMEN: (+)papules on waistline, flat, (-) scars, soft,normoactive bowel sounds, no tenderness, no signs oforganomegally
EXTREMITIES: (+)papules on buttocks and axillae,(+)1 cm.nodule on lateral aspect of right foot, full equalpulses, (-)edema
DRE: no skin tags, no tenderness, no masses,
(-) fecaloid material on examining finger
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SALIENT FEATURES:
13 y/o
Severe itchiness
Worst at night
fever
Lives near a river
Has history of wading in the river
Lives in a crowded community
Papules on waistline, buttocks, axillae
1 cm.nodule on lateral aspect of R foot
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DIFFERENTIAL DIAGNOSIS:
1. Xeroxis
2. Eczemza
3. Psoriasis4. Erysipelas
5. lymphoma
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Xeroxis
RULE IN:
1. Diffuse pruritus
2. No erythema
RULE OUT:
1. Common in elderly
2. Skin appears dry and maybe cracked
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Eczema
RULE IN:
1. itchiness
RULE OUT:
1. Focal scaling skin
2. Principally affects hands and flexor surfaces such asthe popliteal and antecubital fossa
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Psoriasis
RULE IN:
1. Papules
2. Variably prurutic
3. Fairly common
RULE OUT:
1. Absence of plaque-like lesions
2. Not present in the elbows
3. No fingernails involvement
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Erysipelas
RULE IN:
1. swelling of skin
2. Previous trauma due to scratching
RULE OUT:
1. (-) peau d orange
2. No lymphatic involvement
3. No involvement of bridge of nose and cheeks
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Lymphoma
Rule in
1. Nodular enlargement
2. Due to infection and/or inflammation
Rule out
1. Location-mostly in the neck
2. No constitutional symptoms that suggestmalignancy
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SCABIES
The human itch mite,Sarcoptes scabiei, is a commoncause of itching
dermatosis infesting ~300 million persons
worldwide. Gravid femalemites, measuring ~0.3 mm in length, burrow
superficially beneath the
stratum corneum, depositing three or fewer eggs perday.
Nymphs mature in ~2 weeks and then emerge asadults to the surface of the skin, where they mate and
(re)invade the skin of the same or another host
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Pruritus is the most common symptom. The itchingand rash associated with scabies derive from asensitization reaction directed against the excreta thatthe mite deposits in its burrow.
An initial infestation remains asymptomatic for up to6
weeks, and a reinfestation produces a hypersensitivity
reaction without delay. Burrows become surrounded byinfiltrates of eosinophils,
lymphocytes, and histiocytes, and a generalizedhypersensitivity rash later develops in remote sites.
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Hyperinfestation with
thousands of mites, a condition known as crusted
scabies or Norwegian
scabies, may result from glucocorticoid use,immunodeficiency, and
neurologic and psychiatric illnesses that limit itchingand scratching.
Intense itching worsens at night and after a hotshower. Typical burrows
ma be difficult to find because the are few in
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Burrows appear as dark wavy lines in the
epidermis and measure up to 15 mm. Lesions occurmost frequently
on the volar wrists, between the fingers, on theelbows, and on the penis. Small papules and vesicles,often accompanied by eczematous
plaques, pustules, or nodules, are symmetricallydistributed in these
sites and in skin folds under the breasts and aroundthe navel, axillae,
belt line, buttocks, upper thighs, and scrotum. Except
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Scabies should be considered in patients with pruritusand symmetric
polymorphic skin lesions in characteristic locations,
particularly ifthere is a history of household contact with a case.
Biopsies, scrapings of papulovesicular lesions, andmicroscopic
inspection of clear adhesive tape lifted from lesionsmay also
be diagnostic. In the absence of identifiable mites or
mite products, the
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TREATMENT:
Permethrin 5% applied to all areas of the body fromneck down then wash off after 8-14 hrs.
Alternative: lindane 1% 1 oz.lotion or 30 gm. Cream
applied thinly to all areas of the body from neck downthen thoroughly wash off after 8 hrs.
OR Sulfur 6% precipitated in ointment applied thinlyto areas nightly for 3 nights then wash off after 24 hrs.