Vascular Surgery Case Study: Mbchb SIC
Vascular Surgery Case Study: MBChB SIC
Petra Bouwer
MBChB SIC
10214527
Group D3a
A. Patient Demographics:
Name: Elias
Surname: Kgwedi
D.O.B: 10/03/1960
Age: 55
Hospital Number: GP63143155
Firm: Vascular Surgery
Address: 50 Elizabeth Court, Church Street, Pretoria West
Admission Date: 03/06/2015
B. Patient History:
Working Diagnosis:
- Peripheral Vascular Disease of the right lower limb
- Level of disease: Aorto-iliac
Main Complaint:
The patient received a skin graft post-debridement for an ulcer, secondary to lymphoedema, on the anterior aspect of the right lower leg in June 2013. The patient also underwent right-sided Trans-Metatarsal Amputation in May 2015 for a septic diabetic foot. Currently the patient reports that neither the skin graft nor the …show more content…
Normal apex beat palpable in the 5th ICS, MCL. Normal cardiac boarders present on percussion. Normal S1/S2 heart sounds auscultated. No murmurs or additional sounds present.
Respiratory Examination: No scarring or chest deformities observed. Trachea was central on palpation. Normal resonance was present on percussion. Good air entry bilaterally on auscultation.
Abdominal Examination: No scarring, bruising or distention observed. The abdomen was soft and non-tender on palpation and no organomegally was present. Normal bowel sounds were present on auscultation.
Central Nervous System Examination: Normal cognition was present. Power was 5/5 in the upper limbs bilaterally and the left lower limb. Power assessment of the right lower limb was 4/5, but movement was difficult and uncomfortable for the patient at the level of the hip and knee joint. Sensation of fine touch and pain was decreased in the right lower limb up to the level of the right hip. Fine touch and pain was decreased in the left lower limb, but proprioception was still intact. Normal 2+ reflexes present globally. No primitive reflexes
Petra Bouwer
MBChB SIC
10214527
Group D3a
A. Patient Demographics:
Name: Elias
Surname: Kgwedi
D.O.B: 10/03/1960
Age: 55
Hospital Number: GP63143155
Firm: Vascular Surgery
Address: 50 Elizabeth Court, Church Street, Pretoria West
Admission Date: 03/06/2015
B. Patient History:
Working Diagnosis:
- Peripheral Vascular Disease of the right lower limb
- Level of disease: Aorto-iliac
Main Complaint:
The patient received a skin graft post-debridement for an ulcer, secondary to lymphoedema, on the anterior aspect of the right lower leg in June 2013. The patient also underwent right-sided Trans-Metatarsal Amputation in May 2015 for a septic diabetic foot. Currently the patient reports that neither the skin graft nor the …show more content…
Normal apex beat palpable in the 5th ICS, MCL. Normal cardiac boarders present on percussion. Normal S1/S2 heart sounds auscultated. No murmurs or additional sounds present.
Respiratory Examination: No scarring or chest deformities observed. Trachea was central on palpation. Normal resonance was present on percussion. Good air entry bilaterally on auscultation.
Abdominal Examination: No scarring, bruising or distention observed. The abdomen was soft and non-tender on palpation and no organomegally was present. Normal bowel sounds were present on auscultation.
Central Nervous System Examination: Normal cognition was present. Power was 5/5 in the upper limbs bilaterally and the left lower limb. Power assessment of the right lower limb was 4/5, but movement was difficult and uncomfortable for the patient at the level of the hip and knee joint. Sensation of fine touch and pain was decreased in the right lower limb up to the level of the right hip. Fine touch and pain was decreased in the left lower limb, but proprioception was still intact. Normal 2+ reflexes present globally. No primitive reflexes