1601006095 SHORT CASE

 

1601006095 GENERAL MEDICINEMEDICINE- SHORT CASE

MEDICAL CASE DISCUSSION 

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 inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome..

A 35 year old male patient labourer by occupation resident of ramachandrapuram came to OPD with chief complains of painless lesions since 4 months

History of presenting illness-
Patient was apparently asymptomatic 4 months back. 
Then he noticed painless erythemous papules started initially at face and then extended to upper limbs, lower limbs and trunk.
History of blackish discoloration of skin of hands and feet associated with crusting and peeling of skin, burning sensation and redness all over the body since 14 days.
He had history of low grade fever with chills and rigors since 4 days
No h/o discharge or loss of sensations at site of lesions.

Past history- 
No similar complains in the past

Personal history-
Mixed diet 
Normal appetite 
Adequate sleep
Regular bladder and bowel movements 
Addictions- present

Drug history-
 Used topical medication for 2 months 

On Examination-
 Face- Thickening and nodulation of ears and loss of lateral eyebrows are early manifestations 

Trunk- multiple hypopigmented patches with ill defined borders and diffuse erythema is seen

Limbs- dark pigmentation with peeling on sides of legs.
 
PALPATION- No loss of sensations

RESPIRATORY SYSTEM EXAMINATION- 
Trachea midline
Bilateral air entry present 
Normal vesicular breath sounds 
No additional sounds
CVS EXAMINATION- 
S1,S2 heard
No murmurs
CNS EXAMINATION-
Gait- normal
Sensations present 
Cranial nerves - intact 

Investigations-

Provisional Diagnosis-
LEPROSY 

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