CASE OF 35 Y/F WITH FEVER AND ULCERS ON HAND AND FEET
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 .
A
35 year old female, farmer by occupation resident of akaram came to
the OPD with complaints of fever and ulcers on feet and
hands since 5 days
HOPI:
The patient was apparently asymptomatic 5 days ago, then she developed fever which is sudden in onset, continuous, low grade, not associated with chills,rigors,sweating, dizziness, fatigue and body pains, nausea, vomiting .
Second day after onset of fever she went to her farm for work in the early morning and injured her left great toe while harvesting
Third day she noticed progressive painful lesions appearing on both lower limbs and upper limbs chest and neck . Not associated with loss of sensation, itching, joint pains.
Mouth opening is restricted,Difficulty in swallowing and burning sensation in the mouth post consumption of food due to small ulcers in the mouth
No complaints of headache, burning micturition, giddiness, chest pain, shortness of breath, palpitations, cough ,insomnia, loose stools, loss of appetite.
History of usage of semecarpus anacardium for one day.
https://sphinxsai.com/Vol.3No.4/pharm/pdf/PT=30(2080-2084)OD11.pdf
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3249908/
Then she went a local RMP and was prescribed
- deflazocort 6mg for five days
- itraconazole
- tofloxacin
- Clobetalol propionate
- megaheal ointment for five days.
Not a known case of DM /HTN / TB/ Epilepsy / CAD/CVA/ Thyroid disorders
no history of such similar complaints in the past
TREATMENT HISTORY : History of psoriasis vulgaris from 2 years for which she used
TAB.METHOTREXATE 7.5mg BD for one month and capsule itraconazole.
PERSONAL HISTORY :
Patient is 35 year old female belonging to low socio economic status, wakes up in between 5-6 A.M. in the morning and completes her household work by 8 AM, then takes a bath and goes to the farm and recently she harvested her farm during which she met with a trauma to her left great toe.- she takes mixed diet eats non veg once weekly
- appetite is reduced as of now due to her decreased mouth opening and difficulty in swallowing
- she sleeps in between 9-10 PM and sleep is adequate for her
- she denies of any addictions
- bowel and bladder movements are regular
- patient is conscious,coherent, cooperative
- adequately built and nourished
- well oriented to time,place and person
RESPIRATORY SYSTEM:
Inspection: Chest bilaterally symmetrical, all quadrants
moves equally with respiration
Palpation: Trachea central, chest expansion normal
Percussion: Resonant on all the areas
Auscultation : B/l equal air entry, NORMAL VESICULAR BREATH SOUNDS +
CVS EXAMINATION: S1 S2 heard, No murmurs
ABDOMINAL EXAMINATION:
Abdomen is soft and non tender
No organomegaly
No shifting dullness
No fluid thrill
Bowel sounds heard+
CLINICAL IMAGES
03/1/22:
29/12/22
TREATMENT:
- TAB. AUGMENTIN 625mg TID
- TAB DOLO 650mg PO/BD
- FUDIC CREAM
- TAB. FOLINIC ACID 15 mg BD
- ZYTEE GEL
Comments
Post a Comment