CASE

April 14, 2023
Case scenario.....
Hi, This is Swarna Kurma, IIIrd year BDS. This is an online eblog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.

 CASESHEET :A 35 year old man has come to hospital with complaint of itchy skin lesions all over the body since 8 months 


CHEIF COMPLAINTS: 
The Patient was asymptomatic 8 months back then he developed small papule over the chest which transformed into inflamatous scaly lesion first on nose & chest then entire face,neck ,hands &legs.
History of itching over the papule
History of photosensitivity
Tenderness in joint & interphalangeal

 
HISTORY OF PRESENT ILLNESS:
Joint & interphalangeal
History of fever(low grade) in last 8 months last episode 1month back . Fever lasts for one day releived on taking medication 
History of oral ulcers 20 days back
No chest pain 
No Shortness of breath
No palpitations 

HISTORY OF PAST ILLNESS:
No increased or decreased urine output
H/O CVA,left ULGLL weakness & islured speech 10 years back.
H/O of appedectomy 8 years back
Asthma : No Asthma
Tuberculosis : No tuberculosis
CAD : No CAD
CVA : No CVA
Diabetic: No Diabetes 
Thyroid : No Hypo /Hperthyroidism
Epilepsy: No epilepsy


PERSONAL HISTORY: 
Diet : Mixed
Appetite : Normal
Bowel : Normal
Bladder movements : Normal
Addictions : No addictions
Known Allergies : nil

FAMILY HISTORY: 
No significant family history 

GENERAL EXAMINATION:
Patient is Conscious , Coherent and Co-operative 
Built : Moderately 
Nourishment : normal 
Pallor : No 
Icterus : No
Cyanosis : No
Clubbing : No
Lymphadenopathy : No
Edema : No



VITALS:
Temperature: 98°f ( afebrile on touch)
Pulse: 92 beats per minute ( bpm)
Respiratory rate: 16 cycles per minute ( cpm)
Blood pressure: 120 /80mm Hg
SPO2: 95%
GRBS : 211mg %


PROVISIONAL DIAGNOSIS :
The patient was diagnosed with "MIXED CONNECTIVE TISSUE SYNDROME DUE TO ALCOHOL"


Question:
1. What treatment has to be given to patient?





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