Medicine Case Discussion
30 year old female patient with history of painful reddish lesions all over the body.
P.Manasa
9th semester
Roll no:- 102
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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.
Case :-
A 30year old lady resident of Hyderabad, Ayurvedic pg final year student by occupation came to the opd with the cheif complaints of
* painful reddish lesions all over the body (except back , chest ,abdomen) since 1year heals with Hyper pigmented rashes.
History of presenting illness :-
Patient was apparently asymptomatic one and half year back(march 2021), Then she observed pain initially over the left leg following which she noticed a red colour small nodular lesions, initially small (0.5mm)but progressively grown(3mm) spread to face , hands and ears, felt localized rise of temperature which over days healed with hyper pigmented rashes.
Initially she used Ayurvedic medicine for 20days even then the lesions are not completely subsided.
Six months back she developed similar non itchy lesions over both the upperlimbs.
She noticed first {PAIN} next {nodular sensation} , [burning sensation ] and heals with hyper pigmented rashes.
*Bilateral pedal edema since 1month back .
Negative history :-
No history of joint pains, morning stiffness and ulcers etc.
PAST HISTORY:-
She had similar lesions over face, ears 2months back.
She is not a known case of Hypertension,Diabetes, Thyroid , Asthma ,TB and CVS problems etc..
*Renal calculi = one and half year ago
*Symptoms = burning micturation , Abdominal pain radiating back.
#History of firstdose co-vaxin (29th Dec)
*History of Allergic rhinitis yesterday.
PERSONAL HISTORY:-
DIET - MIXED
APPETITE - NORMAL
BOWEL &BLADDER - REGULAR
SLEEP is disturbed
NO ADDICTIONS
NO H/O DRUG ALLERGIES.
Family History:-
No history of similar complaints in the family.
*History of Vitiligo since birth(sister)
GENERAL EXAMINATION
* Patient was examined in well light and good ventilation room after taking consent.
*Patient was conscious , coherent and co- operative.
* Thin built and Moderately nourished.
No Pallor
No Icterus
No Cyanosis
No Clubbing
No Bilateral pedal oedema
No Lymphadenopathy
VITALS
SYSTEMIC EXAMINATION
* CVS - S1 , S2 sounds heard
No murmurs.
* Respiratory system
~Normal vesicular breath sounds heard
~ Bilateral air entry present (BAE+ve)
* Abdomen
soft and Non Tender
Bowel sounds normal
* CNS
No Neurological deficits are seen
No signs of meningial irritation
Gait - Normal.
INVESTIGATIONS:-
Ultrasound
ECG:-
Clinical pictures:-
Face
Arms
Patient is referred to DVL
Investigations :-skin biopsy ,slit skin smear
Provisional diagnosis :-
Cutaneous Vasculitis /ENL(Erythema Nodosum leprosum)?
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