Medicine blog: Medicine prefinal case discussion

Name: Ramya reddy pebbeti

Roll no: 105

This is online E log book to discuss our patient's deidentified health data shared after taking his/her guardian 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 the 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 valuble 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 diagnosis and treatment plan

Following is the view of my case :

CASE PRESENTATION ;

DOA;14/3/22

CHIEF COMPLAINTS;

A 48 year old female resident of hyderabad, homemaker, presented to the OPD with the complaints of

SOB since 1 month(Initially grade 2 progressed to grade 3)
Pedal edema since 1 month
Generalized weakness and fatigue since 1 month
Difficulty in opening mouth and oral ulcers since 1 week
Difficulty in swallowing for both solids and liquids since 4 days

HOPI;

She recieved NSAIDS ,HCQ, PREDNISOLONE FOR RA and she stopped

3 months back around 3/1/22,she was taken to hospital for SOB ,pedal edema , fever where she is diagnosed to have miliary tb (HRCT) she is started on medication(ATT) BUT after 15 days of using she noticed peeling of skin and redness all over her body for which she went to another hospital where she got treated and she stopped ATT ,and in mid Feb she again started ATT and she was fine for 10 days and then on 7/3/22 she c/o SOB, Difficulty in opening mouth and also difficulty in swallowing and burning micturition and fever.

Past History;

_No similar complaints in the past

_She has hypertension, since 10 years (On medication regularly)

_Diabetes since 6 months

_Hypothyroidism since 8 years(On medication regularly)

_Known case of TB since 3months

Personal history:

Diet- Mixed

Appetite- Reduced

Bowel and bladder- Regular

Sleep- Adequate

No history of any addictions

No known allergies

Family history;

No history of tuberculosis in the family

General examination;

Patient is conscious, coherent, cooperative

well oriented to time place and person

poorly nourished

Pallor- present

Icterus- Absent

Cyanosis- Absent

Clubbing-Absent

Lymphadenopathy- Absent

Edema- Present (Non pitting)

Vitals (On admission)-

Temperature- Febrile(Low grade)

Pulse rate- 98bpm)

Respiratory rate- 30cpm

BP- 130/90 mm/Hg

SPO2- 95% at room hair

GRBS- 105 gm%

Head to toe examination;

Alopecia- present

Eyes- Proptosis seen

EOM- Intact

Tongue- ulcers

Thyroid- No goitre

Skin- Multiple hyperpigmented macules all over the face, upper limbs, lower limbs, abdomen and trunk, skin is dry, thickening of skin noted over the forearms, dorsum of hand, and around the mouth, absent of hair, slight peeling is noted over limbs(both) now