Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
NYU Medical Grand Rounds Clinical Vignette Adam Stern MD, PGY-2 April 14, 2010 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Chief Complaint A 45-year-old man from northern India presents with pain, swelling and discharge from his right foot for 15 years. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS History of Present Illness • The patient reports that he was in his usual state of health until 15 years ago when he noted the gradual onset of swelling and pain in his right foot. • He does not recall a preceding traumatic injury, but states that he frequently walked barefoot through the trails near his village leading to frequent skin exposure to thorns and soil. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS History of Present Illness • Initially, the patient noted the appearance of a single nodule on the dorsum of his foot. • Multiple additional nodules developed, grouped closely together, which gradually grew into a mass over time. • He reports the lesion then started to intermittently drain yellow and occasionally blood-tinged discharge. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS History of Present Illness • As the mass continued to grow in size, the foot became increasingly painful. • Prior treatment with ciprofloxacin only partially decreased the drainage and the mass persisted. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Additional History Past Medical History • None Past Surgical History • None Family History • Mother: heart failure UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Social History • Lives in northern India • Eastern Uttar Pradesh • Sells vegetables at a market • Married with 2 children • Lifetime non smoker • Denies alcohol use • Denies illicit drug use Medications • Aspirin 650mg as needed for pain • No known drug allergies UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Physical Examination General: Thin, pleasant man in no apparent distress Vitals: T 98.4, BP 124/78, HR 84, RR 14 Extremities: • Right foot swelling to 1.5-2 times normal size, with hardening of the skin. • Yellow discharge from multiple sinus tracts. • No associated lymphadenopathy. The remainder of the physical exam was normal. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Physical Examination UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Initial test results • CBC: • Hemoglobin 13.3 g/dL, Hematocrit 39.1% • The remainder was within normal limits • Basic Metabolic Panel: was within normal limits • X-Ray of the right foot: No bony abnormalities UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Differential Diagnosis Cutaneous Leishmaniasis Tuberculosis Elephantiasis Actinomycotic mycetoma UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Additional History • Gram stain of the discharge was obtained and demonstrated gram-positive branching filaments, narrow and not fragmenting (0.5-1micrometer) in size. • Acid fast staining and the Kinyoun modification with 1% sulphuric acid were performed and negative. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnosis Actinomycotic mycetoma • Clinical vignette based on: A case of Actinomycotic mycetoma involving the right foot. Tilak et al. J Infect Developing Countries 2009; 3(1):71-73. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Clinical Correlations The NYU Internal Medicine Blog A Daily Dose of Medicine http://clinicalcorrelations.org UNITED STATES DEPARTMENT OF VETERANS AFFAIRS