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    Faculty of Medicine: Dermatology Posting Case Write-Up

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    Aimethevan
    A 65-year-old Indian woman presented with multiple hyperpigmented skin lesions on both legs below the knees for 6 months. She has a history of diabetes, hypertension, and asthma. Physical examination found lesions on her legs and wrists, as well as pedal edema. The impression was bilateral multiple hyperpigmented skin lesions.

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    Faculty of Medicine: Dermatology Posting Case Write-Up

    Uploaded by

    Aimethevan
    28 views3 pages
    A 65-year-old Indian woman presented with multiple hyperpigmented skin lesions on both legs below the knees for 6 months. She has a history of diabetes, hypertension, and asthma. Physical examination found lesions on her legs and wrists, as well as pedal edema. The impression was bilateral multiple hyperpigmented skin lesions.

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    A 65-year-old Indian woman presented with multiple hyperpigmented skin lesions on both legs below the knees for 6 months. She has a history of diabetes, hypertension, and asthma. Physical examination found lesions on her legs and wrists, as well as pedal edema. The impression was bilateral multiple hyperpigmented skin lesions.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    28 views3 pages

    Faculty of Medicine: Dermatology Posting Case Write-Up

    Uploaded by

    Aimethevan
    A 65-year-old Indian woman presented with multiple hyperpigmented skin lesions on both legs below the knees for 6 months. She has a history of diabetes, hypertension, and asthma. Physical examination found lesions on her legs and wrists, as well as pedal edema. The impression was bilateral multiple hyperpigmented skin lesions.

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    © All Rights Reserved
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    FACULTY OF MEDICINE

    DERMATOLOGY POSTING
    CASE WRITE-UP
    PATIENT DETAILS

    NAME : MRS X
    AGE : 65
    GENDER : FEMALE
    RACE : INDIAN
    OCCUPATION : GROCERY SHOP OWNER
    MARITAL STATUS : MARRIED
    ADDRESS : KB KELANTAN

    CHIEF COMPLAINT
    Multiple hyperpigmented palpable skin lesions at bilateral legs for 6 months
    HISTORY OF PRESENT ILLNESS
    - A 65 years old Indian lady with underlying diabetes mellitus on diet control,
    hypertension, bronchial asthma presented to dermatology clinic with a chief complaint of
    multiple palpable hyperpigmented skin lesions at both of the legs below knee region.
    - Patient claimed that initially there was small whitish spots at the both of the legs below
    knee region then it became itchy and blackish.
    - Patient mentioned that there are some hyperpigmented skin lesions at her back and wrist
    regions as well.
    - Patient claimed that she had intermittent fever.
    - Patient claimed that there was no serous, blood or pus discharge from those lesions.

    PAST MEDICAL HISTORY


    - Patient has Diabetes mellitus under diet control
    - Patient has hypertension
    - Patient was diagnosed with bronchial asthma 20 years ago and on medications

    DRUG HISTORY
    - T Perindopril 5mg
    - T Montelukast 10mg
    - Salmeterol 1 puff
    - Salbutamol 2 puffs

    ALLERGY HISTORY
    - No significant history of allergies
    FAMILY HISTORY
    - There’s no other significant family history
    - There is no malignancy history in the family

    SUMMARY
    - A 65 years old Indian lady with underlying diabetes mellitus, hypertension, and bronchial
    asthma presented to dermatology department with a chief complaint of multiple palpable
    hyperpigmented skin lesions at both of the legs below knee region.

    PHYSICAL EXAMINATION FINDINGS


    - On examination, the patient is alert, conscious, not tachypnoeic, talk in full sentences, had
    warm peripheries and capillary refill time less than 2 seconds.
    - Vital signs BP : 138/84
    PR : 76
    RR : 28
    T : 37.3
    SPO2 : 100 % under room air

    - Lungs clear, equal air entry


    - CVS – dual rhythm no murmur
    - Abdomen – soft and non-tender
    - Bilateral pedal oedema up to midshin
    - No lymph node palpable
    - There are some small skin patches on the right and left anterior wrist

    IMPRESSION:
    1. Bilateral multiple hyperpigmented skin lesions

    PLAN:
    1. Medication is given
    2. Follow up

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