33 Year old female with recurrent oral ulcers.
"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 also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome."
History given patient daughter as patient was unable to speak
A 33 year old female who is a house wife by occupation came with the complaints of recurrent oral erosions since 10 months.and lesions over the abdomen and back since 10 months
HOPI : patient was apparently normal 10 months back, followed which one day patient was travelling in an auto , suddenly slipped and fell down from the auto ..pt had injury to the left ear and used medication (analgesics) from RMP for about 1week. After few days one day, patient husband had a dispute with his brothers ( due to property issues ) ,his husband was hit by his brother because of this she didn't ate for one day ..the next day patient ate normally ,the following day patient developed a small red coloured lesion(which doesn't has any pus point) on the left side of the oral cavity ,above the molars which was painful and patient neglected the lesion and carried on with her work.after one week the patient developed another lesion beside the initial lesion ..with the days progressing the lesions are developing one by one in a line followed by the healing of old lesions with in 7- 10days ....patient took some treatment from RMP which didn't gave her any relief..then the patient visited dermatologist ,where the treating doctor gave hope that it was not at all dangerous to her life and suggested to use some medications...Patient had complete relief,no fresh lesions are seen up to 1 month.following 1 month the patient again started developing the same painful l lesions on the oral cavity,below the tongue ,the patient visited the same dermatologist ,so the treating doctor said it was due to her dysregulation in the subsequent follow up and patient was started on another treatment ,which gave only a partial relief but the patient was not satisfied with his treatment ..so they went to hospital in kodada, where the patient didn't got any relief from the doctor and was referred to KIMS for further evaluation.The patient was initially treated by dermatology team, inspite of disputes regarding pain management between treating team and patient attenders ,the case was taken over by medicine team.
H/o redness of eyes with pain present occasionally but the patient attenders attributed it to the lack of sleep
No h/0 such lesions on the vaginal and anal regions .
No h/o of joint pains , pain during rest or walking .
No h/o of chest pain, palpitations ,shortness of breath.
No h/o focal neurological deficit , seizures and loss of consciousness.
No such complaints in the past .
Aggravating factors: Eating Chicken and Brinjal according to patient family members.
Relieving factors : Medications.
HISTORY OF PAST ILLNESS : NOT A KNOWN CASE OF HTN, DM, BA, TB,
EPILEPSY . NO OTHER KNOWN COMORBIDITES .
GENERAL EXAMINATION : PT IS C/C/C ORIENTED TO TIME , PLACE AND PERSON .
NO PALLOR , CYANOSIS, LYMPHADENOPATHY , CLUBBING , ICTERUS , EDEMA .
ON LOCAL EXAMINATION : MULTIPLE ERYTHEMATOUS PAPULES NOTED OVER THE
ABDOMEN , TRUNK ( POSTERIORLY ) . VAGINAL MUCOSA - CURDY WHITE
DISCHARGE .
MULTIPLE EROSIONS OVERE THE BUCCAL MUCOSA AND HARD PALATE , WHITE
COATED TONGUE . ( WHITE ADHERENT PKLAQUE NOTED OVER THE DORSAL SURFACE
OF THE TONGUE ).
SYSTEMIC EXAMINATION :
CNS : GCS 15\15 , NO ABNORMALITY DETECTED.
CVS - S1,S2 HEARD , NO MURMURS .
RS : NVBS HEARD , NO ADDED SOUNDS .
P/S : VAGINA MUCOSA WITH CURDY WHITE DISCHARGE .
inv
SERUM ELECTROPLYTES : Na : 137 m Eq /L , K : 4.7 mEq /L , Cl : 107 mEq /L .
CUE : ALB : + , SUGARS : NIL , PUS CELLS : 3-4 , EPITHELIAL CASTS : 2-3.
HIV : NON REACTIVE .
Investigations:
RECURRENT ERYTHEMA MULTI FORME SECONDARY TO HSV
? CHRONIC APHTHOUS ULCERS
? BECHETS DISEASE
? CHRONIC CANDIDIASIS.
Treatment given by intial treating team ( dermatology)
1] DNS -3
2] ORS SACHETS
3] INJ. PAN -D OD BBF
4] WARM SALINE GARGLES
5] INJ. PCM IV SOS
6] WATCH FOR BREATHING DIFFICULTY
7] PLENTY OF ORAL FLUIDS
8] TAB. ACELO-P BD
9] TAB. OFLOX -OZ 200 MG BD
10] SYP. CREMAFFIN 15 ML H/S
11] OINT. ANOBLISS L/A ANAL REGION
Treatment given by medicine team:
1) IV fluid NS @ 50 ml/hr
2) Inj.TRAMADOL 1 ampule in 100ml NS IV over 30min
3) Syp MUCAINE GEL 10ml/ PO / TID
PRESENT CONDITION : The patient had pain relief after medication today.
Comments
Post a Comment