25 yr old male with purpurea evaluation
17/08/2022
Eblog2
Hi, I am shaik karishma , 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'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 come up with a diagnosis and treatment plan.
CHIEF COMPLAINTS :
Painful skin lesions over the fingertips and sole since 4 days
H/o burning sensation over epigastric region since one month
History of present illness:
Patient was alright 4days back, he had complaints of painful lesions over fingertips and sole and history of burning sensation over epigastric area and in associated with dry cough,headache since on month. He had abdominal tightness and back pain and also his metacarpophalengeal joint were aggrevating on work.
Past history:
Decreased appetite since 4 years and no similar complaints in past
Negative history:
No fever
No diabetes
No hypertension
No coronary artery disease
No TB
No asthma
Used antibiotics
No chemo/radiation
Personal history:
Loss of appetite
Regular bowels
Normal micturition
No ALLERGIES
family history:
No diabetes
No hypertension
No stroke
No TB
No asthma
No cancer
GENERAL EXAMINATION
No pallor
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
No oedema
No malnutrition
No dehydration
VITALS
Pulse: 95bpm
BP : 100/80 mmhg
SYSTEMIC EXAMINATION
CVS
no thrills
Cardiac sounds S1 S2 present
Cardiac murmurs absent
RESPITORY SYSTEM
no dyspnoea
No wheezing
Centrally placed trachea
Vesicular breathe sounds
ABDOMEN
scaphoid shape
Tenderness present
No palpable mass
Hernial orifices are normal
Free fluid absent
Liver and spleen were not palpable
Bowel sounds present
Genitals normal
CNS
conscious
Normal speech
No neck stiffness
Cranial nerves normal
Motor system normal
Sensory system normal
Reflexes are present in triceps,biceps,supinator and knee
Ankle reflexes are absent
Cerebellar signs:
fingernose coordination absent
INVESTIGATIONS
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