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Initials: M.BAge: 12 DOB: 2/2/2002 Encounter: 2014 Ethiopia(S) CC HPI: Difficulty and pain in left leg and foot with ambulation for approximately 5 years. Also deformity/change in length noted approximately 3 years ago. Character: deep throbbing and achingOnset: 5 years agoLocation: left lower leg and footDuration: 5 yearsSeverity: current 6/10Pattern: constantAssociated: standing or walking makes it worseMedical/surgical history: Left lower leg fracture 6 years ago. Surgery performed 5 hours away from her village in Addis. Unknown what type of surgery or which bone was fractured. No clinics in the area and she is not followed by a physician. No medical records available.Family/Social: Lives in an orphanage in Fiche, Ethiopia. Denies tobacco use, illicit drug use, or alcohol use. Denies sexual activity. In the 6th grade.Immunization status: unknown but generally are not given in this area.Meds: N/AAllergies: NKDAROS:General: complains of fatigue. denies changes in weight or appetite. HEENT: denies ear pain, changes in vision, or nasal congestion. Resp: denies shortness of breathCardio: denies chest painGI: denies nausea, vomiting or changes in bowelsGU: denies pain during urination Diet: regular diet. Endocrine: denies heat or cold intolerance MS: complains of pain in lower left leg and foot and difficulty walking and standing. Neuro: Denies confusion, memory loss, head or neck injury, dizziness, loss of sensation or tremors. Psych: Denies depression and anxiety. Denies suicidal or homicidal ideation. Says she is sad that she can’t do what the other kids can. She has to sit while they play.Skin: Denies rash or open wounds. States she has a scar on her left lower legVital signs – T -99.0F P- 88 R- 20 BP- 120/72 HT-4’9” WT- 96lbs BMI-20.8 Pain –current 6/10, worse it gets 8/10, best it gets 3/10, tolerable 3/10Constitutional: Patient alert, oriented, and well groomed. Patient appears uncomfortable sitting in chair. HEENT: Head: Normocephalic; no apparent trauma. Eyes: PERRLA bilaterally, no exudate. Ears: TM’s translucent bilaterally with minimal cerumen noted. Skin is smooth and intact. Nose: external skin smooth and intact; mucosa smooth and intact without edema. Throat: bilateral tonsil surfaces without erythema or edema. Lymph nodes non palpable non tender.Respiratory: Respirations are even and unlabored; lung sounds clear to auscultation in bilateral upper and lower lobes. Cardio: Heart rate and rhythm are regular with no murmur or gallops noted GI: Bowel sounds normo-active in all four quadrants. No visible pulsations noted. No masses or tenderness noted upon palpation. Renal, aorta, and iliac arteries without bruits. GU: not assessed Endocrine: not assessed MS: uses a stick to walk. Has an obvious limp with a 6 cm discrepancy between the right and left leg. Patient has limited ROM in left knee and ankle, muscle strength of left lower extremity was 3/5. DTR’s in patellar and Achilles of left extremity absent. Patient guarding limb so difficult to assess actual ROM. Patient started crying during the physical assessment of the lower left extremity stating it was painful. States increased pain while weight bearing. ROM in upper extremities intact DTR’s intact, and muscle strength 5/5. Right lower extremity with ROM intact, DTR’S intact and muscle strength 5/5. Pedal and patellar pulses intact. DTR’s in patellar and Achilles of left extremity abscent. Neuro: Superficial touch intact in upper and lower extremities. See musculoskeletal exam for DTR’s and gait assessments. Psych: not assessedOther - Skin: edema and redness noted on lower left shin. An 8cm scar noted on the lower left shin. (A)Dx: (include ICD 9 code - )(list as many diagnoses as indicated) Diagnosis: Chronic Osteomylitis- 730.16 Differentials: 1 Osteosarcoma-170.7 2 Hardware malfunction- 996.49 3 Lower leg injury- 959.7 (P)(Include costs of tests, medications, etc. – can find resources for this at ; , )– Prescription: Provided 6 months worth of multivitamins. No Rx given. Patient needs cultures, CBC, CRP, and ESR to determine infection and causative agent so the correct IV antibiotic can be given.A MRI needs to be performed to determine the extent of bone involvement and loss.Surgical intervention is likely needed in this case for debridement and possible reconstruction of the bone and soft tissue. Patient may also require bone stabilization via external fixation.This patient most likely has stage 3 -4 Osteomylitis. Antibiotics are generally unsuccessful in these stages without debridement. These are services that we cannot provide in our makeshift global health clinic.We contacted the hospital in Addis Abba to set up these services including the anticipatory surgery and immediately transported the patient and a representative from the orphanage. Education/Anticipatory Guidance: Educated the patient and representative on the care and treatment that she will be receiving while at the hospital. We also educated on the importance of the follow up care that may be needed post hospitalization. We contacted a Christian group based in the area to set up follow up transportation as needed in the future. Educated on nutrition and clean water especially during recovery.Discuss how you addressed at least 3 NONPF competencies during this visit. (See NONPF competency list)1) B. Management of Patient Illness 1. Analyzes and interprets history, including presenting symptoms, physical findings, and diagnostic information to develop appropriate differential diagnoses.2) A. Health Promotion/Health Protection and Disease Prevention 1. Differentiates between normal, variations of normal and abnormal findings.3) B. Management of Patient Illness 5. Formulates an action plan based on scientific rationale, evidence-based standards of care, and practice guidelines. What I wish I had done differently: I don’t think I would have done anything differently. Difference of opinion with the preceptor: No differences.What I will do differently next time: With this particular patient situation in this remote area with little resources, I would not change my approach. What I learned from this experience: I learned how debilitating this disease can be when left untreated over long periods of time. ReferencesIkpeme, I.A., Ngim, N.E., Ikpeme, A.A. (2010). Diagnosis and treatment of pyogenic bone infections. African Health Sciences. 10(1), 82-88. Retrieved from ncbi.nlm.pmc/articles/PMC2895795/#_ffn_sectitle ................
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