General Medicine
Hii this is E.Bhargavi,3rdBDS student.This is an online eblog book to discuss our patients health data after taking his consent . This is reflects my patient centered online learning portfolios
Case scenario:
A 35 yr old female from suryapet she was a farmer she has redness and itching all over the body
Chief complaint:
C/o Redness redness scaling and itching all over the bodies since 1 month
C/o fever since 15 days that is evening raise of temperature and reduced on medication
History of present illness:
Patient was apparently alright one month back present complaint started as itching redness over the thighs sudden in onset 10 days later progressed to abdomen two days later progress to all over the body. sparing tip of nose and soles. loosely adherant white scales and handfull of scales lost everyday.Associated with burning,dryness; No H/o joint paints, atopy photosensitivity, weight loss, burning micturition,proximal muscle weakness,varicose veins ,edema feet H/O winter exacerbation(+)
H/O Fever:low grade,sudden in onset ,with evening raise of temperature,associated with chills and rigors.
History of Past illness:
H/O same complaints in past since 10yrs on and off 2 to 3 episodes/years
H/O usage of cycloproine 50mg-4months Antihistamines, Antibiotics,calcipotriol Haloesteraes ointment, Methotrexate 7.5mg approx (irregular)Acetretin 25mg-15days (5years ago)
H/O usage of Ayurvedic medicine,salytar lotion,Halox-5
Known Comorbidity-underwent surgery for CAD 9 years back,No other comorbidity
No Family History
H/O usage of Amiloride+Furosemide (40mg) Iosartan (25mg),digoxin(0.25mg),Lansoprazole(30mg) Ferrous Ascorbate Follic acid .
No Diabetes,No Hypertension,No Asthama.
PERSONAL HISTORY:
Marital status:Married
Appittite:Normal
Diet: Mixed
Bowels: regular
Micturition: Normal
Addictions No
Known allergies:No
FAMILY HISTORY:
Diabetes :No
Hypertension:No
Heart disease:No
Stroke:No
Cancer:No
Tuberculosis:No
Asthama:No
GENERAL EXAMINATION:
Built:Thin
Nourishment:well nourished
Pallor:No
Clubbing:No
Cyanosis:No
Icterus:No
VITALS:
BP:110/70mmHg
PR:70bpm
SYSTEMIC EXAMINATION:
a) cardiac examination
Thrills:No
Cardiac sounds:S1 S2 (+)
Cardiac Murmurs :No
ECG:
b) Central Nervous system examination:
Level of consciousness: conscious
Speech:Normal
HEMORRHAGE
DIAGNOSIS:
ERYTHRODERMA 2° to CHRONIC PLAQUE PSORIASIS
TREATMENT:
Drugs/Tablets
Tab FOLUITE 5mg
Tab TECZINE 5mg
Tab ATKRAX 25mg
Tab SMELCAL 0.3mg
Tab MVT
LIQUID PARAFFIN+GLYCERIN +WATER(1:1:1)
