final practical examination long case

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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 30 yrs old female patient presented to OPD with a complain of red coloured painful lesions all over the body.

History of present illness:

Patient was apparently asymptomatic 1year back then she observed pain initially over skin of left leg following which she noticed a small nodular lesion initially small with reddish discoloration but progressively grown and felt localized rise in temperature which over days healed with hyperpigmented rashes. Intially she used ayurvedic medicine for few months even then the lesions did not subside completely. 6 months back she developed similar non itchy lesions over both hands extending proximally and healed with hyperpigmented rash.

History of past illness:

Since 8 months she developed similar lesions on face and from 1 and half to 2 months she developed similar lesions on ears etc currently not healed.

No history of DM, HTN, TB, Asthma

Personal history:

Mixed diet

appetite -normal 

bowel and bladder - Normal

no addiction 

No known allergies

Family history:

No familial resemblance of similar condition in any known relatives.

Physical examination:

no signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy, oedema, dehydration.

Vitals:

temperature - afebrile 

pulse rate - 82 bpm 

RR - 18 cpm 

BP - 130/80 mm hg 

SPO2 - 98 on RA 

GRBS - 117.mg %

Systemic examination:

CVS-S1 ,S2 heard ,no murmurs 

RS -BAE +, NVBS

 P/A - soft ,non tender 

CNS -

speech - normal 

 power 

U.L - 5/5 

L.L - 5/5

TONE - normal 

REFLEXES 

KNEE - ++

BICEP - ++

TRICEP-++

ANKLE - ++

BRACHIORADIALIS - ++

PLANTAR - withdrawal

Provisional diagnosis:

ERYTHEMA NODOSUM LEPROSUM (CUTANEOUS VASCULITIS)

Investigations:

Hemogram:

Liver function test:

Complete urine examination:

ECG:

Ultrasonography:

Radiograph:

Treatment:

Topical application of fudic cream BD for 1 week