A 35 year old man came to medical OPD with hypopigmented patches.
General medicine E-Blog
Hi, I am N .Annmaria , 3rd Sem Medical Student.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 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 a diagnosis and treatment plan.
CHIEF COMPLAINT:
A 35 year old married man, working as a tractor driver, resident of Bhongir came to medicine OPD with
Chief complaints of increase in size of the discolouration of skin since 8 months
A 35 year old married man, working as a tractor driver, resident of Bhongir came to medicine OPD with
Chief complaints of increase in size of the discolouration of skin since 8 months
HISTORY OF PRESENT ILLNESS-
The patient was apparently asymptomatic 8 months ago.
He suddenly noticed heat rashes over the nose area. It was not itchy. The rash persisted for 15 days.
The skin started peeling off of the rashes with skin hypopigmentation and mild pain.
After 10 days, he decided to consider herbal medicine and took it for 15 days which was not of any help.
The patches kept spreading to his chest, upper limb and legs over the next 15days.
The skin peeling continued and was associated with fever in the evenings after coming back home from work.
He went to a local doctor and took medicine with saline administered for 3months. The fever subsided on medication with decrease appetite(no significant weight loss) and burning sensation and itchiness over patches and headache over the bitemporal region .
The patches became itchy and had a burning sensation on exposure to sunlight and water.
He then went to the Nalgonda for the treatment 2 months ago and was on it for 1 month.
Later, he went to Hyderabad 1 month ago and the treatment didn’t help him much
15 days ago, he went to Khammam hospital and was on treatment-
Ointment clobestarol and fused if acid
Ointment momentasone
Liquid Paraffin lotion
Tab. Levocitrazene
Where they recommended the patient to come to KIMS
He had joint pain in his wrist joint, which then included interphalangeal joints and ankle joint. No radiation. No aggravating and relieving factors.
The joint pain was mainly in the morning with morning stiffness because of which his movement was restricted, which interfered with his work(lifting loads).
No h/o vomiting, constipation, burning micturition
The skin started peeling off of the rashes with skin hypopigmentation and mild pain.
After 10 days, he decided to consider herbal medicine and took it for 15 days which was not of any help.
The patches kept spreading to his chest, upper limb and legs over the next 15days.
The skin peeling continued and was associated with fever in the evenings after coming back home from work.
He went to a local doctor and took medicine with saline administered for 3months. The fever subsided on medication with decrease appetite(no significant weight loss) and burning sensation and itchiness over patches and headache over the bitemporal region .
The patches became itchy and had a burning sensation on exposure to sunlight and water.
He then went to the Nalgonda for the treatment 2 months ago and was on it for 1 month.
Later, he went to Hyderabad 1 month ago and the treatment didn’t help him much
15 days ago, he went to Khammam hospital and was on treatment-
Ointment clobestarol and fused if acid
Ointment momentasone
Liquid Paraffin lotion
Tab. Levocitrazene
Where they recommended the patient to come to KIMS
He had joint pain in his wrist joint, which then included interphalangeal joints and ankle joint. No radiation. No aggravating and relieving factors.
The joint pain was mainly in the morning with morning stiffness because of which his movement was restricted, which interfered with his work(lifting loads).
No h/o vomiting, constipation, burning micturition
PAST HISTORY-
10 years ago, He had complete loss of movement and sensation of his left upper limb and left lower limb with loss of speech.
There was no deviation of mouth or ptosis of eyelid.
No h/o trauma to head
He took herbal medicine only for 3 days after which he gained both his movement and sensation to normal.
9 years ago, appendicitis surgery in Karimnagar
3 years ago, head injury( a brick fell from a height) for which he had a minor surgery in Hanumankonda
No h/o HTN, DM, Asthma, CAD, Thyroid, TB, Epilepsy.
There was no deviation of mouth or ptosis of eyelid.
No h/o trauma to head
He took herbal medicine only for 3 days after which he gained both his movement and sensation to normal.
9 years ago, appendicitis surgery in Karimnagar
3 years ago, head injury( a brick fell from a height) for which he had a minor surgery in Hanumankonda
No h/o HTN, DM, Asthma, CAD, Thyroid, TB, Epilepsy.
FAMILY HISTORY- no significant history
PERSONAL HISTORY-
• Diet mixed
• Appetite normal
• Sleep adequate
• Bowel and bladder movements regular
• Allergies none
• Addictions- beedi- 1pack /day for past 25 years and alcohol 90ml/day for past 10 years
General Examination
• The patient was conscious
• Well oriented with time, place and person
• Cooperative and coherent
• No pallor
• No icterus
• No cyanosis
• No clubbing of fingers
• No lymphadema
• No pedal oedema
• Diet mixed
• Appetite normal
• Sleep adequate
• Bowel and bladder movements regular
• Allergies none
• Addictions- beedi- 1pack /day for past 25 years and alcohol 90ml/day for past 10 years
General Examination
• The patient was conscious
• Well oriented with time, place and person
• Cooperative and coherent
• No pallor
• No icterus
• No cyanosis
• No clubbing of fingers
• No lymphadema
• No pedal oedema
VITALS
• Pulse-88 bpm
• Temp- afebrile
• Pulse-88 bpm
• Temp- afebrile
Comments
Post a Comment