GEN MED E -LOG AUG 10

 E-LOG GENERAL MEDICINE


Hi, This is easha chandrika, a fifth semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from  patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them.

A 66 YRS OLD WITH ENTEROCOCCUS INFECTION 

Chief complaints:

A 66 year old male hailed from bhuvanagiri presented to the OPD with chief complaints of

Itching all over the body since 5 yrs

Painful pustules and blisters since 3 days

HOPI:

Patient was normal 5 yrs back and then devloped itching all over the body on and off 3 months back

Patient took blackmagic treatment then he devloped painful lesions 10 days back over both the legs and hand

PAST HISTORY:

DM since 5yrs

HTN since 3yrs

no h/o similar complaints in the past

FAMILY HISTORY : nill significant 

PERSONAL HISTORY:

Mixed diet

Appetite-normal

Sleep-adequate 

Bowel and bladder habits-normal

No allergies

No addictions(occasionally alcohol)

TREATMENT HISTORY:

diabetic medication since 5 yrs

HTN medication since 3 yrs 

GENERAL EXAMINATION:

Temperature - 98.4°F

Pulse - 76 beats/min

BP - 120/80 mmHg

RR -18 cycles/min

SPO2 - 98 %

Pallor - No

Icterus -No

Clubbing - No

Cyanosis - No

Lymphadenopathy - No

SYSTEMIC EXAMINATION :

CVS :

No thrills

No murmurs

S1 and S2 heard

RESPIRATORY SYSTEM :

Position of trachea - Central

No Dyspnoea , Wheeze

Breath Sounds - vesicular

 ABDOMEN :Soft

Shape - Scaphoid

No palpable mass

Tenderness :no

No free fluid present

Bowel sounds heard 

CNS : Normal

- Patient is Conscious, Coherent well oriented to surroundings.

REFLEXES : Normal

SKIN:

Multiple polysized bullae , pustules with erosions, crusting,oozing, bleeding noted over both tighs, legs, buttocks, dorsum of both hands ,chest

Swelling of middle finger distal phalanx of left hand

INVESTIGATIONS:









USG:



PROVISIONAL DIAGNOSIS :

? bullous pemphigoid

? Eczema with 2° bacterial infection 

? folliculitis + acute paronychia 

? Bullous Impetigo 

TREATMENT:

2/8:


3/8:


4/8&5/8:

6/8:


7/8:

8/8:

9/9:

10/10:






















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