93 N. Lavanya , 3 rd semester student .

This is my elog 

Cheif complaints

46 year old male came to the OPD with complaints of burning sensation in the feet (bilaterally) since 6 months.

The pain was not associated with pedal oedema, tingling/numbness. There was no slippage of foot.

Also, it wasn't associated with tingling and numbness/ hyperpigmentation of skin

There was history of recurrent episodes of running nose, sore throat, cough (maybe due to allergic rhinitis)

There was also history of trauma to the left leg, erythematous patch was seen on the left leg which subsided by itself. History of oozing is present.


History of presenting illness 

The erythematous patch on the left leg was followed by itchy lesions of dorsum of feet bilaterally. Hyperpigmented lesion on both feet with lichenification of right foot.

History of past illness 

Not a known case of hypertension, diabetes mellitus, 

tuberculosis, epilepsy, CVA

Treatment History 

No significant treatment history.

Personal History

Appetite: normal

Diet: mixed

Bowels: regular

Micturition: normal

The patient has history of atopy. No habits or addictions

Family History 

No family history of diabetes, hypertension, 

heartdisease, stroke, cancers, tuberculosis, asthma

Physical examination

No pallor

icterus

cyanosis

clubbing of fingers/toes

lymphadenopathy

oedema of feet

malnutrition

dehydration

Vitals 

Temperature: afebrile

Pulse Rate: 70bpm

Respiratory rate: 12 breaths per minute

BP: 140/100 mm of Hg

SPO2: 99%

GRBS: 109mg%

Systemic examination 

CVS: S1, S2 sounds heard

Respiratory system: No dyspnoea, position of trachea is central, breath sounds are vesicular.

Abdomen: shape of abdomen is obese, bowel sounds heard, genitals are normal.

CNS: The patient was conscious and alert.

Diagnosis 

Peripheral neuropathy, Lichen Simplex Chronicus

Investigations 

ECG:-


Blood Sugar Fasting:-





Serum Creatinine:-


Post Lunch Blood Sugar:-

Serum Electrolytes (Na, K, Cl):-

Blood Urea:-
Complete Urine Examination (CUE):-


Glycated Haemoglobin:-

Clinical findings 

Cross Consultation Notes and Treatment:-46/M was brought to casualty with complaints of burning sensations in the feet (bilateral). It was not associated with pedal oedema, tingling/numbness, hyperpigmentation of the skin. There was no slippage of the foot. There was history of recurrent episodes of running nose, sore throat, cough, possibly due to allergic rhinitis. There was also history of trauma to the left leg, erythematous patch was seen on the left leg which subsided by itself. History of oozing is present. This was followed by itchy lesions of dorsum of feet (bilateral). Hyperpigmented lesion on both feet with lichenification of right foot were seen.

Personal History: Diet is mixed. Appetite is normal. Sleep is adequate. Micturition is normal. Bowel movements are regular. No habits/addictions.

Examination: Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis, lymphadenopathy, clubbing, oedema.

Vitals: Temperature: afebrile

Pulse Rate: 70bpm

Respiratory rate: 12 breaths per minute

BP: 140/100 mm of Hg

SPO2: 99%

GRBS: 109mg%

CVS: S1, S2 heard, no murmurs

Respiratory system: No dyspnoea, position of trachea is central, breath sounds are vesicular.

Abdomen: shape of abdomen is obese, bowel sounds heard, genitals are normal.

CNS: The patient was conscious and alert.

Psychiatry:-

Comments

Post a Comment

Popular posts from this blog

Image
 N.lavanya   2019 Internee A 80 year old female who is a homemaker was brought to casualty with unresponsiveness with h/o involuntary movements of both upper limbs since 11pm previous night, 5-6 episodes lasting for 15mins        This is an a online e log book to discuss our  patient de-identified health data shared after taking  his / her / guardians signed informed consent. Here  we discuss our individual patients problems  through series of inputs from available global  online community of experts with an aim to solve    those patients clinical problem with collective  current best evident based input This E blog also reflects my patient centered online  learning portfolio and your valuable inputs on the  comment box is welcome. The patient/ attender was informed the purpose of  the information being acquired. An informed  consent was taken from patient/ attender and there    is omission of information that was requested to be omitted A 80 year old female who is a homemaker was brou
Read more
Image
                                    N. Lavanya                         Internee 2019      A 75 year old female   came with chief complaints of   involuntary  tonic movements  of right upper limb with  deviatioon of mouth to left side on  30/4/24        This is an a online e log book to discuss our  patient de-identified health data shared after taking  his / her / guardians signed informed consent. Here  we discuss our individual patients problems  through series of inputs from available global  online community of experts with an aim to solve    those patients clinical problem with collective  current best evident based input This E blog also reflects my patient centered online  learning portfolio and your valuable inputs on the  comment box is welcome. The patient/ attender was informed the purpose of  the information being acquired. An informed  consent was taken from patient/ attender and there    is omission of information that was requested to be omitted Chief complaints :  Invol
Read more

A 21 yr old female student from miryalaguda came with c/c shortness of breath

Image
N.lavanya                                   Roll  93  This is 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  patients clinical  problems with collective current best  evidence based inputs.    A 21 year old female  resident of miryalaguda  student by occupation came to general medicine op with.  Chief complaints :  Itching of the skin over hands and feet with swelling since 2 days   Shortness of breath since 7 days  History of presenting illness :  Patient was apparently asymptomatic 19 years back than at the age of 2 she developed acute  edema over the fronto parietal region associated  with fever and irritability she was admitted in the hospital and got treated (  mentioned about  swelling relieved on lumbar puncture )  At the age of 4 sh
Read more