Skip to main content

K.MANASA, HALLTICKET NO:1601006081 - shortcase

"This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.  Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.  This E log book also reflects my patient-centered online learning portfolio and your valuable 

CASE OF MULTIPLE SKIN LESIONS 

A 23 year old lady , psychologist by occupation resident of nalgonda came to opd with c/c of painful skin leisions over the upper and lower limbs and back of trunk since 8 months 

HISTORY OF PRESENT ILLNESS:

Patient was apparently assymptomatic 8 months back she developed multiple red lesions on both upper limbs not associated with burning or itching after 1 week she developed itching and burning then she consulted local doctors who prescribed some medications but leisions didn't subsided so she referred to another hospital Where she diagnosed HENOCH SCHOLEIN PURPURA

EXAMINATION:

GENERAL PHYSICAL EXAMINATION:

patient is conscious, coherent,cooperative and moderately built and moderately nourished 

VITALS:

→ patient is afebrile

→ BP-110/80 mm Hg

→ PR-70 bpm

→ RR-16 Cpm

✓SpO2- 98%

✓GRBS - 122gm/dl

No Pallor, Icterus, Cyanosis, clubbing, Odema, lymphadenopathy.

ON INSPECTION:

red erythematous lesions Over Hands, legs, Palms and Soles including Web Spaces








CNS EXAMINATION:

  • Higher mental functions-normal 
  • Cranial nerves- intact
  • Sensory system- normal
  • Motor system- normal 
  • Meningeal signs- absent 
  • Cerebellar signs- absent

CVS EXAMINATION:

INSPECTION:

No scars sinuses and engorged ve

No visible pulsation

PALPATION:

apical impulse : heard in fifth inter coastal spac

ASCULTATION:

S1 and S2 heard

No murmurs 

RESPIRATORY SYSTEM EXAMINATION:


INSPECTION OF UPPER RESPIRATORY SYSTEM:

oral cavity- normal

Nose- normal 

Pharynx- normal 

LOWER RESPIRATORY TRACT:

INSPECTION:

trachea: central 

Symmetry of chest : symmetrical 

Movement: B/L symmetrical expansion of chest respiration

No scars, engorged veins or sinuses.

PALPATION:

All inspectory findings are confirmed by palpation.

Trachea: central - confirmed by three finger test.

Assessment of anterior and posterior chest expansion- B/L symmetrical expansion of chest.

No chest wall tenderness 

Vocal fremitus- normal

PERCUSSION:

done in sitting position 

Resonant

AUSCULTATION:

Vesicular breath sounds heard

Bilateral air entry present

No added sounds

ABDOMINAL EXAMINATION:

INSPECTION:

Shape : elliptical 

Quadrants of abdomen moving in accordance with respiration.

Umbilicus- central and inverted

No scars sinuses or engorged veins 

PALPATION:

No tenderness 

No organomegaly

PERCUSSION:

tympanic 

ASCULTATION:

Normal 

No organomegaly , no tenderness.

INVESTIGATION REPORTS:
















PROVISIONAL DIAGNOSIS: - HENOCH SCHONLEIN PURPURA ( Leucocytoclastic Vasculitis)

TREATMENT: 

At present patient is using:

Tab. Dapsone 100mgS

Syruporofer 5mlT

Tab Shelcal










Comments

Post a Comment

Popular posts from this blog

A 40 YR OLD MALE

Unit 6 admission  A 48 yr old male, farmer by occupation & resident of Nakrekal.came to casualty with CHEIF COMPLAINTS: 1.Fever since 1wk 2.Swelling in the right lower limb since 4 days 3.Pain over the swelling since 2 days 4.Loose stools  since 4 days (4 episodes/day) HISTORY OF PRESENT ILLNESS  : pt was apparently asymptomatic 1 wk back then, he developed  1. FEVER : - low grade, intermittent type, associated  with chills & rigors & relieved by medications. - pt is k/c/o Rt lower limb filariasis since 20 yrs - Due to filariasis, pt used to have fever spikes for every 6 months since 20 yrs. for which he used to take medications & fever relieved - Recently After 3 yrs, he again had a bout of fever spikes since 1 wk.for which he got admitted to a local hospital in nakrekal and took medications. & also found decrease of platelet count 2. SWELLING IN THE RIGHT  LOWER LIMB :  - pt had trauma over rt lower limb 4 ...
Post a Comment
Read more

42 YEAR OLD WOMEN WITH MULTIPLE HEALTH EVENTS

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment Following is my analysis of this patient's problem: The problems in order of priority I found  1.Swelling 2.Headache( Migraine) 3. Muscle weakness  4. Mouth ulcers 5. Excessive Hair Growth 6. Kidney dysfunction-Oligouria 7.Poor vision 8.Left hand numbness 9. Autism 10. Broken Leg 11. Intolerance to some kind of food SWELLING Swelling is present since 1 year age. It is mostly present on face and abdomen. Swelling aggravated on exposure to smoke, emotional stress, physical activity, certain drugs such as sulpha drugs and foods like fava beans She also presented with severe jaundice at the time of birth. All these features are seen in Oxidative stress. KIDNEY DYSFUNCTION-OLIGOURIA It is also seen in Oxi...
Post a Comment
Read more

A 19 YR OLD FEMALE

Unit 6 admission  A 19 yr old female, student by occupation & resident of Nagarjun sagar .came to casualty with  COMPLAINTS OF  1.Fever since 3 days 2.Vomitings 5 episodes since 1 day 3.Stomach pain since 1 day 4.Loose stools 2 episodes since 1 day 5. Cough with expectorantion since 1 day HISTORY OF PRESENT ILLNESS  : 1.FEVER - 3 days back she had -  Insidious onset of fever, low grade, intermittent type, Relieved on taking medications.subsided with in a day - Not associated with chills and Rigors. 2.VOMITINGS: - 5 episodes/ day since 1 day - non projectile,non bilious, contain food particles initially & later watery 3.STOMACH PAIN : - Diffuse type,increased after vomiting episode 4.LOOSE STOOLS : - 2 episodes/day - small inquantity - Not associated with pain abdomen, bloody stools -ve,Tenesmus -ve 5.COUGH WITH EXPECTORATION : - expectoration - small in quantity, light green color  - cough is not associated with diurnal variations,cough is more in r...
Post a Comment
Read more