This is an 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 patient’s clinical problems with collective current best evidence based inputs. This e-log book reflects my patient centered online portfolio and your valuable inputs on the comments is welcome.”
a29yr old Female ,who is an homemaker has come to tha OPD with the cheif complains of
✓B/L knee joint pains since 10months
✓pigmentation on the face ,neck ,upper part of chest and on back since 10months
HOPI
there are 2 members in the family lives with an avg income of 500/day
daily routine ` wakes up at 5 o'clock ,offers her prayers and sleeps. then wakes up at 7:30 Am ,freshes up ,drinks tea and bread & she does the household works viz.cooking,washing clothes etc., eats every meal with her husband she time passes with her neighbours for a while and cooks dinner ,they eat meat twice a week and rarely takes leafy vegetables ,sleeps at 9:30pm'
# Joint pain
gradual in onset, constant, aggravated on walking, relieved on taking medication or rest.
there is also pain in other joints viz.,shoulder jnt , elbow, wrist, interphalangeal,hip,knee,ankle(at achilis tendon)
early morning stiffness of joint is present
# Skin Pigmentation
since 10months she is having itching over the chest neck etc then it got pigmented gradually
there are Pigmentations on upperpart of chest,neck, face,back, fingers both on volar and dorsal aspect etc.
she also complains of SOB and
c/o heavy ness in chest
c/o alopecia
the width of PIP joint seem to be increased
no h/o symptoms of hyperthyroidism
Treatment h/
she used some meditation for infertility (aurvedic) for 20days and stoped since she developed these symptoms.
No other treatment history
past H/o
no similar complaints in the past
no allergies
no Tb,Htn,Dm, thyroid, epilepsy, asthma
personal h/o
diet-mixed
appetite -decreased
sleep- inadequate due to pain
Bowel and bladder moments- regular
addictions-No
Menstrual H/o
3days for every 25days
cycles are regular
h/o white discharge 10months ago for two months
marietal History
age of marriage 14yrs
Nulliparous (infertile)
The couple went up for t/t of infertility in the form of tablets...where they are fed up and stoped using them.
family history
no similar complaints
General physical examination: The patient is conscious, coherent, cooperative well oriented to time, place and person. She is moderately built and moderately nourished.
Pallor- present
No icterus, cyanosis, clubbing, pedal edema ,lymphadenopathy.
(Pedal Edema was present the day before)
Vitals:
Temperature- Afebrile
BP- 130/80 mm Hg
PR- 102 bpm
RR- 14 cpm
SpO2- 99% @ RA
SYSTEMIC EXAMINATION:
CVS- S1, S2 sounds heard. No murmurs
RS- BAE+ NVBS heard
CNS- NAD
P/A- Soft, non tender, Bowel sounds heard
1. T FLUCONAZOLE 150MG/PO/OD
2. CANDID CREAM FOR L/A
3. T PAN 40 MG PO/OD
4. T ULTRACET 1/2 TAB /PO/QID.
5. SYP GRILLINCTUS BM 10ML/PO/TID
6. SYP MUCAINE GEL 10ML/ PO/TID
PROVISIONAL DIAGNOSIS:
DERMATOMYOSITIS WITH PRIMARY INFERTILITY
GENITAL CANDIDIASIS
?SLE
Comments
Post a Comment