1802102031 LONG CASE FINAL PRACTICAL EXAMINATION

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have 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 diagnosis and treatment plan.

CHIEF COMPLAINTS

30 year old female came to casuality with c/o painful lesions along the body since past one year.

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 1 year back then she observed pain initially over skin of left leg following which she noticed a small nodular lesion initially small with reddish discoloration.
But progressively grown and felt localized rise in temperature which over days healed with hyperpigmented rashes. 
Initially she used ayurvedic medicine for few months even then the lesions did not subside completely.
Six months back she developed similar non itchy lesions over both hands extending proximally and healed with hyperpigmented rashes
Pain, Nodules and then burning sensation they heal with hyperpigmentation.

PAST HISTORY

Since 8 months she developed similar lesions on face and from 1 and half to 2 months, she developed similar lesions on ears etc which are currently not healed.

Not a known case of hypertension, asthma, diabetes, TB.

PERSONAL HISTORY

Adequate diet 

mixed diet

regular bowel and bladder movements

sleep: adequate

no consumption of alcohol and smoking

FAMILY HISTORY

No history is seen in family

No cases of hypertension and diabetes

TREATMENT HISTORY

Not allergic to any of the known drugs

PHYSICAL EXAMINATION

GENERAL

Patient is coherent, cooperative and conscious.

proper nourishment and proper build is seen.

pallor   - Present



Icterus    - absent

Lymphadenopathy- absent

clubbing - absent

cyanosis - absent

Pedal edema  - absent






VITALS

temperature - afebrile 
pulse rate - 82 bpm 
RR - 18 cpm 
BP - 130/80 mm hg 
SPO2 - 98 on RA 
GRBS - 117.mg %

SYSTEMIC EXAMINATION

CVS-S1 ,S2 heard,no murmurs 
RS -BAE +, NVBS
 P/A - soft ,non tender 
CNS - NAD
speech - normal power 
U.L - 5/5 
L.L - 5/5

TONE - normal 

REFLEXES:

KNEE - + 
BICEP - + 
TRICEP-+
ANKLE - + 
BRACHIORADIALIS - + 
PLANTAR - withdrawal

INVESTIGATIONS:










PROVINSIONAL DIAGNOSIS:

ERYTHEMA NODOSUM LEPROSUM (CUTANEOUS VASCULITIS)

TREATMENT:

Topical application of fudic cream BD for 1 week.

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