Short case medicine final examination discussion

 Short case :final practical

June10,2022.

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.

June 10,2022

RAMYAREDDY PEBBETI

Hall ticket number;1701006138

Case discussion;

A 12 year old boy ,who is a 7th standard student, resident of miryalaguda ,stays in the hostel ,he is taken to the hospital by his father with chief complaints of 

# itching all over  body but more in the web spaces of fingers of hands since 10days .

#HOPI:

he was apparently asymptomatic 10  days ago ,then he noticed  itching involving all over the body . itching is insidious in onset , gradually progressive and  more during night time.

No h/o fever, vomiting and diarrhea

No h/o cough and cold

#PAST HISTORY;

No similar complaints in the past

No h/ o asthma, TB, epilepsy 

No h/o drug intake

#FAMILY HISTORY:

No similar complaints in the family 

But his roomate is having similar complaints in the hostel.

#PERSONAL HISTORY;

Diet ;mixed 

Appetite;normal

Bowel and bladder: regular 

Sleep : disturbed due to itching since 4 days

No known drug allergies

#GENERAL EXAMINATION;

He is examined in a well lit room and after adequate exposure.

He is conscious, coherent, cooperative and well oriented to time ,place and person.

He is moderately built and moderately nourished.

#VITALS :

Temperature: Afebrile

Pulse rate; 95bpm

RR; 18 CPM

BP:110/80mmhg ,measured in sitting position in left upper arm

#SYSTEMIC EXAMINATION;

*RS: BAE - present,no added sounds

*CVS;S1,S2 heard,no murmurs 

*PER ABDOMEN:soft and non tender,No organomegaly.

*CNS: Intact

#CUTANEOUS EXAMINATION;

ON Examination,there are papules and excoriated lesions over finger web spaces and periumbilical region.

#PROVISIONAL DIAGNOSIS;

*SCABIES.

#Investigations;

Hemogram;

•Hb-12g%

•Tc-normal

•Platelets -normal

KOH mount;

*Shows eggs and adult mites.

#Treatment;

*Tab.levocet-for 15 days OD at night time

*Permethrin 5%lotion ,apply all over the body below neck before going to bed and keep it  for atleast 12 hours and repeat it after one week. 

#Advice;

*All family members are given the same treatment.

*All used clothing and bedsheets should be kept aside for 10 days, washed and dried under sunlight .