A 55 year old female patient came to the OPD with c/o itchy skin lesions over back, hands , neck , face, and fever

June 07, 2023

A 55 year old female patient came to the OPD with c/o itchy skin lesions over back, hands , neck , face, and fever

Hi, I am Ananya Aleti a 5th Sem 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.

CONSENT AND DE-IDENTIFICATION :

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

A 55 year old female patient came to the OPD with

C/o 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 normal 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,Mouth Reynauds phenomenon.

History of swelling of face One month back.

No H/o chestpain,Dyspnea,palpitations

H/o photosensivity present

H/o elephantiasis of right leg since 25yrs

H/o diarrhoea and vomiting since 15 days

Denovo detected hypothyroidism

H/o usage Tab.omnacortil 30mg,T.Augmentin 625mg,Betamethasone lotion