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.
A 17 year old male patient who completed his Inter,goes to wage work occasionally,resident of Mangalpally presented to the opd with the chief complaint of itchy ring lesions & purple striae on abdomen,hands & legs.
History of present illness:
Patient was apparently asymptomatic 8 months back then he developed round lesions on hands & legs.Then he developed purple striae on chest,abdomen,hands & legs which gradually increased in size.Round lesions aggravated on taking meat.Later he noticed facial puffiness & pedal edema.
H/o skin ulcer on abdomen.
No history of cold,cough,nausea,vomiting
No history of hematuria
No history of buring micturition.
No bleeding gums.
History of past illness:
The patient was known case of hypertension & under medication since 6 months.
No a known case of diabetes mellitus,bronchial asthma,epilepsy & tuberculosis.No history of any surgeries.
Personal history:
Mixed diet
Bowel & bladder - Normal
No addictions
Sleep adequate
Family history:
His father had similar round lesions but only localised to hands.
General Examination:
The patient is conscious,coherent and cooperative.He is well oriented to time,place and person.
No Pallor
No Icterus
No Cyanosis
No Lymphadenopathy
Pedal Edema present
Temperature - 97.8 degrees F
Pulse rate - 78 bpm
Respiration Rate - 17/min
Blood pressure- 160/100
SpO2 99% at room air.
Systemic examination:
CVS : No thrills
S1 S2 +
RS- Bilateral air entry +
per abdomen- soft,non tender,Purple striae,skin ulcer seen
CNS- Conscious,Speech normal.
Provisional diagnosis- ?Cushing’s syndrome
?Tinea corporis
Investigations :
Complete Urine Examination:
Liver Function Test:
Complete Blood Picture:
Glycated Hemoglobin:
Ultrasound Report:
ECG :
Renal Function Tests :
Serum Creatinine-0.7 mg/dl
Blood urea - 27 mg/dl
Serum electrolytes :
Sodium - 144 mEq/L
Potassium - 4.0 mEq/L
Chloride- 98 mEq/L
Treatment:
25/11/2021
Tab.Telma-AM 40/5 mg
Tab.Itraconazole 100mg
Tab Anxit 0.25 mg
Tab.MVT
26/11/2021
Tab.Telma 40/5 mg
Tab.Metformin 500 mg
Tab.Itraconazole 100mg
Tab.Levocitrizine 10mg
27/11/2021
Tab.Telma 40/5 mg
Tab.Atarax 25mg
Tab.Sebifin 250mg
30/12/2021
Tab.Telma 40 mg
Tab.Atarax 25 mg
Tab.Sebifin 250mg
Tab.Shelcal 500mg
Comments
Post a Comment