Hi, I am Peddineni Manasvi, 3rd sem medical student.This is an online elog book to discuss our patients health data after taking their consent.This also reflects my patient centered online learning portfolio.
Case scenario
A 25 year old male patient came to the OPD on August 11th with chief complaint of painful lesions over soles and fingertips since 4 days
Chief Complaint
- painful lesion over soles and fingertips since 4 days
History of present illness
- burning sensation over epigastric region since 1 month
- abdominal tightness associated with headache and dry cough
- no fever or similar complaints in the past
- weight loss and decreased appetite since 2 to3 years
- medication: oflaxacin, amoxicillin, rabeprazole, paracetamol, multivitamins
- back pain aggravates over exertion
On Examination:
- petechia, purpura noted over fingertips and soles, sublingual right ring finger
Personal History:
- married
- mixed diet
- bowel : regular
- micturition: normal
- no known allergies
- no addictions
Family History
- no diabetes mellitus
- no hypertension
- no heart disease
- no stroke
- no cancer
- no tuberculosis
- no asthma
- no other hereditary diseases
Physical Examination
- height: not taken
- weight: 45 kgs
- BMI: not taken
- no icterus
- no cyanosis
- no clubbing of fingers
- no lymphadenopathy
- no edema of feet
- no malnutrition
- no dehydration
Vitals
- BP: 100/80 mm Hg
- Pulse: 95bpm
Systemic Examination
Cardiovascular System:
- no thrills
- cardiac sounds S1 and S2 heard
- no cardiac murmurs
Respiratory System
- no dyspnea
- no wheeze
- trachea position: central
- breath sounds: vehicular
Abdomen
- shape: scaphoid
- no tenderness
- no palpable mass
- no bruits
- no free fluid
- hernias orifices: normal
- liver: not palpable
- spleen : not palpable
- no bowel sounds
- genitals: normal
- speculum examination : normal
- PV examination : normal
- P/R examination : normal
Central Nervous System
- conscious
- normal speech
- no neck stiffness
- no Kerning's sign
- cranial nerves: normal
- sensory : normal
- motor: normal
- reflexes: all present bilaterally except ankle reflex which is completely absent
- no finger nose coordination
Skin
- petechia, purpura noted over fingertips and soles, sublingual right ring finger
Investigations
11/08/2022
- chest X ray
-CRP
- ESR
- ECG
-HIV
- USG abdomen
- RBS
- RA factor
- ALP = 311 IU/L
- LFT
- RF: within normal limits
- Hemogram :
Total count = 44,000
Neutrophils = 7
Lymphocytes = 8
Eosinophils = 84
Smear = Eosinophilic leukamoid reaction
14/08/2022
- Hemoglobin = 13
- PCV = 37
- TLC = 36,000
- RBC = 4.5
- Platelet = 2
- Neutrophils = 15
- Lymphocytes = 8
- Eosinophils = 75
- Monocytes = 2
16/08/2022
- Hemoglobin = 13.1
- PCV = 37.8
- TLC = 16,700
- RBC = 4.62
- Platelet = 2
- Neutrophils = 40
- Lymphocytes = 12
- Eosinophils = 46
- Monocytes = 2
ECG:
RFT:
