This is 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 patients 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 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
D.Santhosh (Internee)
Case History and Clinical Findings
- PATIENT WAS APPARENTLY ASYMPTOMATIC 15 DAYS BACK THEN DEVELOPED PAINFUL
- LESIONS ON THIGHS WHICH GRADUALLY PROGRESSED TO BOTH LEGS, ARMS, BUTTOCKS.
FACE
- HISTORY OF USAGE OF TOPICAL LULICONAZOLE ON AND OFF FOR 15 DAYS
- HISTORY OF NAUSEA AND VOMITING SINCE 15 DAYS
- HISTORY OF LOSS OF APPETITE, DIFFICULTY SWALLOWING SINCE 15 DAYS
- HISTORY OF WEIGHT LOSS SINCE 1 MONTH
- PATIENT WAS ADMITTED ONE MONTH BACK WITH H/O FEVER, ORAL ULCERS, SHORTNESS
OF BREATH, HAIR LOSS, PAINFUL LESIONS OVER BODY.
- HISTORY OF UNKNOWN MEDICATIONS AND TOPICALS USED FOR ONE MONTH
- NO HISTORY OF PHOTOSENSITIVITY, JOINT PAINS
- NO HISTROY OF EPISTAXIS, NASAL STUFFINESS, SLIPPAGE OF FOOTWEAR
- NO KNOWN COMORBIDITIES
- FAMILY HISTORY INSIGNIFICANT
ON EXAMINATION..
-MULTIPLE 1X2CM ULCERS NOTED OVER BOTH ELBOWS, PALMS, DORSUM OF BOTH
HANDS, BUTTOCKS, INNER THIGHS, WITH ERYTHMATOUS BORDER.
- TENDERNESS PRESENT, NO LOCAL RISE OF TEMPERATURE
- MULTIPLE HYPERPIGMENTED PLAQUES NOTED OVER ALL 4 EXTREMETIES, BUTTOCKS
RAW AREA PRESENT OVER DORSUM OF LEFT FOOT (OOZING PRESENT)
- XEROSIS PRESENT
- LONGITUDINAL RIDGES PRESENT ON TOE NAILS
- SCALP: DIFFUSE THINNING OF HAIR PRESENT
- ORAL CAVITY NORMAL, PATIENT TAKEN TO ENT REFERRAL IVO PAIN DURING SWALLOWING SINCE 1 MONTH.
- BETADINE GARGLES DILUTED IN WATER 3-4 TIMES A DAY PATIENT TAKEN TO GASTRO REFERRAL IV/O NAUSEA AND VOMITING SINCE 15 DAYS,
- LOSS OF APPETITE SINCE 15 DAYS, DIFFICULTY SWALLOWING SINCE 15 DAYS.
- ADVISED UPPER GI ENDOSCOPY WITH FASTING PATIENT TAKEN TO GASTRO REFERRAL IN VIEW OF NAUSEA AND VOMITING SINCE 16 DAYS,
LOSS OF APPETITE SINCE 15 DAYS, DIFFICULTY SWALLOWING SINCE 15 DAYS
- ADVISED UPPER GI ENDOSCOPY WITH FASTING PATIENT TAKEN TO GM REFERRAL W/O NAUSEA AND VOMITING, INABILITY TO STAND
FROM SITTING POSITION
TREATMENT GIVEN :
TAB DOLO 650 MG SOS
FUDIC CREAM L/A BD X 4 DAYS
BETADINE GARGLES DILUTED IN WATER TID X3 DAYS
TAB PAN 40MG PO OD X 4 DAYS
TAB AUGMENTIN 625MG TID X-2-DAYS
TAB THYRONORM 25MCG PO OD X 2DAYS
SYRUP ASCORYL D 10ML PO BD X 2 DAYS
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