Case 1

Hi, I am R. Ramya Keerthana , 3rd semester medical student.This is an online elog book to discuss our patient's health data after taking his/her consent.This also reflects my patient centered online learning portfolio.

Case Scenario 
A 25 year old male patient came to the hospital on 11th August with chief complaints of painful lesions 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
- weight loss and decreased appetite since 2-3 years
- back pain aggravating on work
- no fever or similar complaints in past 

Drug history
Ofloxacin, Amoxicillin, Rabeprazole, Paracetamol, Multivitamin tablets.

History of past illness
No diabetes, hypertension history.

Personal History
Married
Occupation: driver
Appetite: decreased
Bowel and bladder movements are normal 

Family History
No history of diabetes, hypertension, stroke, cancer, tuberculosis, asthma.

Physical examination
No icterus, no clubbing, no edema , no cyanosis, no lymphadenopathy, no dehydration.

Vitals
BP: 100/80 mm Hg
Pulse rate: 95bpm

Systemic examination 
CVS
No thrills, no cardiac murmurs, S1 SE are heard.

Respiratory system
No dsypnoea, wheezing
Breath sounds: vesicular
Trachea in central position

Abdomen
Scaphoid shape, no tenderness, no palpable mass, no free fluid, liver and spleen not palpable
Bowel sounds heard

CNS 
Conscious, normal speech
No neck stiffness
Kerning's sign: negative
Cranial nerves, motor system, sensory system normal
Reflexes: all except ankle reflex present bilaterally
Cerebellar: finger nose coordination absent

Skin
Petechia, purpura on fingertips (subungual right ring finger) and soles.

Investigations 
Hemogram
Hemoglobin: 13gm/dl
PCV: 37 vol%
Total leukocyte count: 36000 cells/cu.mm
Neutrophils: 15 %
Lymphocytes: 8%
Eosinophils: 75%
RBC count: 4.5 millions/cu.mm
Platelet count: 2 lakhs/cu.mm

Smear
Eosinophilic leukemoid reaction

Ultrasound
Spleenomegaly

LFT
RFT
ECG

Medication Chart 
Inj Pan 
Tab Atarax
Tab Pantop
Tab Ultracet
Tab PCM





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