General medicine case discussion

April 15, 2023

 General medicine case discussion

E LOG MEDICINE CASE

15/04/2023

This is is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed 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 protfolio and your valuable inputs on comment box is welcome.

Name : Mamatha. N

Roll no : 65

2020 Batch

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 comeup with Diagnosis and Treatment plan.

CASE DISCUSSION

Date of admission:11/04/2023 

A 35 year old male resident of Bhongiri working as a tractor driver came to opd with 

CHIEF COMPLAINTS :

Increase in the size of  discoloration of skin on face, right and left forearms, chest and right and left lower limbs. 

History of Present Illness:
The patient was apparently asymptomatic 8 months ago and suddenly noticed heat rashes over the nose area. It was not itchy ,not associated with pain. The rash persisted for 15 days.
The skin started peeling off of the rashes after 15 days 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 decreased 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 
Ointment momentasone
Liquid Paraffin lotion
Tab. Levocitrazene
Where they recommended the patient 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.
3 years ago, he had 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.

Personal history :

Sleep:  Adequate 

Diet : Mixed 

Appetite: Normal 

Allergies : None 

Addictions- beedi- 1pack /day for past 25 years and alcohol 90ml/day for past 10 years.

Family history :

No significant family history. 

General examination :

Conscious

Coherent 

Cooperative 

Well oriented with time, place and person
Pallor- Absent 

Icterus - Absent 
Cyanosis - Absent 
Clubbing of fingers - Absent 
Lymphadenopathy- Absent 

Pedal oedema - Absent 

Vitals: 
Pulse - 88 bpm
Temperature - Afebrile