A 55year old female came with rashes all over the body

Hi, I am Sravya , 5thSem 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 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 a diagnosis and treatment plan. 

CHIEF COMPLAINTS
Itchy lesions over back,neck,face since 3 months 
Initially started over back and progressed to hands   
C/o fever since 2 months(one episode per day in the evening)
Complaints of oral ulcers since 1 month
C/o joint pains since 15 days 

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic  3 months back And started Having itchy lesions over back its progress to hands,Neck. oral ulcers since one month.

High grade fever, one episode per day, relieved on taking medication.
Joint pain since 15 days associated with swelling. 

No history of morning stiffness.painful oral ulcers since one month, associated with difficulty in swallowing and burning sensation.

History of two episodes of vomiting,Non projectile, non bilious with food particles non blood tinged.

History of three episodes of diarrhea per day for two days, which is water in consistency. No occult blood is present in stools. No history of new drug intake prior to symptom.

 No history of dry eyes.

History of swelling of face One month back.

No H/o chestpain,Dyspnea,palpitations

H/o photosensivity present 

H/o diarrhoea and vomiting since 15 days 


PAST HISTORY 
NO H/O DM, HTN, Asthma ,TB, CAD
H/o elephantiasis of right leg since 25yrs
Denovo detected hypothyroidism 

FAMILY HISTORY 
Insignificant
 
GENERAL EXAMINATION 

Pt is conscious, coherent and cooperative 

No Pallor,Icterus,cyanosis, clubbing lymphadenopathy, pedal oedema

Afebrile on touch
PR:70 bpm
BP:130/70 mm hg
RR:26 cpm
GRBS:106mg/dl 
.   SYSTEMIC EXAMINATION
RESPIRATORY EXAMINATION

Inspection:
No Tracheal deviation.
Chest bilaterally symmetrical
Type of respiration: thoraco abdominal.
No dilated veins,pulsations,scars, sinuses.
No drooping of shoulder.

Palpation:
No Tracheal deviation
Apex beat- 5th intercoastal space,medial to midclavicular line.
Tenderness over chestwall- absent.
Vocal fremitus- Mammary,Infra Axillary and Infrascapular- Decreased on both sides.

Percussion:                  
Resonant note on all areas 

Auscultation:
NVBS,BAE +

CARDIOVASCULAR EXAMINATION

Inspection : no visible pulsation , no visible apex beat , no visible scars.

Palpation: all pulses felt , apex beat felt.

Percussion: heart borders normal.

Auscultation: 

Mitral area, tricuspid area, pulmonary area, aortic area- S1,S2 heard.

P/A:Soft ,Non-tender

CNS:

HMF-Intact

Memory -recent and remote:Intact

Speech-Normal


INVESTSIGATIONS
                    2/6/23

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