1601006094 SHORT CASE

 

1601006094 ( SHORT CASE)


A 23 year old lady , psychologist by occupation resident of nalgonda came to opd with c/c of painful skin leisions over the upper and lower limbs and back of trunk since 8 months 

HISTORY OF PRESENT ILLNESS:
Patient was apparently assymptomatic 8 months back then she developed multiple red lesions on both lower limbs not associated with burning or itching after 1 week she developed itching and burning sensation.

History of Joint pains initially in the left wrist later Progressed to left elbow .

History of abdominal pain present. 

She consulted local doctors who prescribed some medications but leisions didn't subsided so she referred to another hospital.

She was asked for  CUE, ASO TITRE, ESR, RFT,Serum Bilirubin which was normal and diascopy showed Non blanchable palpable erythamatous Purpura 

Examination : 

general physical examination:

patient is conscious, coherent,cooperative and moderately built and moderately nourished 

Vitals: 

patient is afebrile

BP-110/80 mm Hg 

PR-70 bpm 

RR-16 Cpm

SpO2- 98%

GRBS - 122gm/dl

No Pallor, Icterus, Cyanosis, clubbing, Odema, lymphadenopathy.

INSPECTION

red erythematous lesions Over Hands, legs, Palms and Soles including Web Spaces

*CNS examination:

  • Higher mental functions-normal 
  • Cranial nerves- intact
  • Sensory system- normal
  • Motor system- normal 
  • Meningeal signs- absent 
  • Cerebellar signs- absent

*Cvs examination: 

Inspection :

No scars sinuses and engorged ve

No visible pulsation

Palpation:

apical impulse : heard in fifth inter coastal spac

Auscultation:

S1 and S2 heard

No murmurs heard


Respiratory system examination:

Inspection of upper respiratory system- 

oral cavity- normal

Nose- normal 

Pharynx- normal 

Lower Respiratory Tract:

Inspection: 

trachea: central 

Symmetry of chest : symmetrical 

Movement: B/L symmetrical expansion of chest respiration

No scars, engorged veins or sinuses.

Palpation:

All inspectory findings are confirmed by palpation.

Trachea: central - confirmed by three finger test.

Assessment of anterior and posterior chest expansion- B/L symmetrical expansion of chest.

No chest wall tenderness 

Vocal fremitus- normal

Percussion : 

done in sitting position 

Resonant

Auscultation: 

Vesicular breath sounds heard

Bilateral air entry present

No added sounds

*Abdominal examination:

Inspection:

Shape : elliptical 

Quadrants of abdomen moving in accordance with respiration.

Umbilicus- central and inverted

No scars sinuses or engorged veins 

Palpation:

No tenderness 

No organomegaly

Percussion:

tympanic 

Auscultation:

Normal 

No organomegaly , no tenderness.

PROVISIONAL DIAGNOSIS

HENOCH SCHONLEIN PURPURA

Investigations reports:

Haemogram showed normochromic normocytic Blood Picture with Neutrophilic leucocytosis 









TREATMENT: 

At present patient is using:

Tab. Dapsone 100mgS

Syruporofer 5mlT

Tab Shelcal



Comments

Post a Comment

Popular posts from this blog

  2K16 BATCH UNIVERSITY PRACTICAL EXAMS    DEPARTMENT OF GENERAL MEDICINE   DATE: 26.04.2021 (MONDAY) S. NO HALLTICKET NO CASE BLOG LINKS  CASE PRESENTATION VIDEO LINKS      1 1601006001 LONG CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006001-long-case-april-23-2021-hall.html SHORT CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006001-short-case-april-25-2021.html https://youtu.be/9xE26ZkzqDg 2 1601006002 LONG CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006002-long-case.html SHORT CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006002-short-case.html https://youtu.be/7jBj-Fz8kc4 3 1601006003 LONG CASE https://mbbs2k16batchgmpracticals.blogsp...
Read more

1601006161 SHORT CASE

Image
  SHORT CASE : A 34-YEAR-OLD GENTLEMAN WITH CHRONIC KIDNEY DISEASE UNDERGOING DIALYSIS   HALL TICKET NUMBER : 1601006161 A 34-year-old gentleman, from Motukur, who is a labourer by occupation, came to the hospital on 17/04/2021, for Maintenance Hemodialysis. History of presenting illness : The patient was apparently asymptomatic 3 years ago, when he was diagnosed with  Hypertension, secondary to Chronic Kidney Disease.  He was regularly taking his medication for Hypertension, until he  abruptly stopped  doing so 2 months ago. The patient has been  undergoing maintenance hemodialysis at our hospital since the past 10 months . He complains of facial puffiness, abdominal distension and swelling in the legs.  The patient also complains of loss of weight over the past 3 years. Initially, he was 63 kg, now he is 52 kg. General Physical Examination : The patient is conscious, coherent and cooperative, lying supine on the bed He is well oriented to time, ...
Read more

1601006107 LONG CASE

Image
  LONG CASE : A 50-YEAR-OLD LADY WITH LEFT-SIDED WEAKNESS OF THE BODY AND DEVIATION OF THE MOUTH TOWARDS THE RIGHT A 50-year-old lady, from Suryapet, who is a homemaker, came to the hospital on 20/04/2021 at 3 PM, and was examined on 24/04/2021 at 10 AM, with Chief Complaint s  of : 1) W eakness of the left upper and lower limbs since 5 days 2) Deviation of the angle of mouth towards the right since 5 days 3) Slurred speech since 5 days. History of Presenting illness  :  The patient was apparently asymptomatic  5 days ago , when  at around 9 AM in the morning, on 20/04/2021 : She felt a sudden  weakness of her left upper and lower limbs. The episode was  sudden in onset, initially began as a slight weakness of the left upper limb, which progressively worsened with time and the evolution of weakness had completed within 6 hours ,  with a complete inability to move both - her left upper and lower limbs ,   following which she was brought t...
Read more