A CASE OF 25F WITH FEVER SINCE 3 MONTHS

NOTE:

The following E-log aims at discussing our patient de-identified health data shared after taking the guardian's signed consent.

Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.

This E-log also reflects my patient's centered online learning portfolio.

I have been given this case to solve in an attempt to understand the topic of "Patient Clinical Data Analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and providing treatment best to our skills and wisdom.

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted.

A 25yr old patient, daily wage worker by profession , presented to the casualty with complaints of fever and multiple skin lesions over both legs with suspected systemic lupus erythematous.

CHIEF COMPLAINTS

➤ Multiple skin lesions over both legs since 4 days .

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 6 years back . Then during her second pregnancy , she developed hyperpigmented lesion over her both cheek initially small in size which latter progressed to butterfly shaped lesion.

Since 3 months she is having high grade fever and went to rmp and used medication She also had abdominal pain for which she was admitted in our hospital on 26/8/23 and was treated as acute gastritis .

After discharge she developed skin lesions over b/l lower limbs associated with itching which later progressed to painful pus filled ulcers over b/l lower limbs ,over left elbow and lumbosacral region

Since 3 months she has complaints of hairfall and multiple joint pains i.e in elbow,wrist joint,interphalengeal joints and knee joint .

She had 2 episodes of generalized tonic seizures for about 2 minutes with uprolling of eyes , lip biting 5 days ago . Not associated with involuntary micturition, defecation ,frothing.

No previous abortion history

Since 3 months she has ammenorrhoea.

HISTORY OF PAST ILLNESS

➤Not a K/c/o diabetes, hypertension, asthma , epilepsy tuberculosis , CAD

➤No surgical history

➤No history of Blood transfusions.

PERSONAL HISTORY

➤Occupation: Farmer.

➤Patient is married .

➤Patient takes mixed diet and has a normal appetite

➤Sleep : Regular

➤Bowel and bladder movements are normal.

➤No known allergies and addictions.

FAMILY HISTORY

Not significant .

GENERAL EXAMINATION

➤Pallor : Seen

➤Icterus : Not seen

➤Cyanosis : Not seen

➤Clubbing : Not seen

➤Lymphadenopathy : Not seen

➤Edema : Not seen

VITALS

➤Temperature : 98.3℉

➤PR : 90 beats per minute

➤BP : 100/70 mm of Hg

➤RR : 20 cycles per minute

➤SpO2 : 96% in room air

➤Blood Sugar (random) : 97mg/dl

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM EXAMINATION

➤s1 and s2 heard

➤Thrills absent.,

➤No cardiac murmurs

RESPIRATORY SYSTEM

➤Normal vesicular breath sounds heard.

➤Bilateral air entry present

➤Trachea is in midline.

ABDOMINAL EXAMINATION

INSPECTION

➤Shape - Scaphoid

➤Equal movements in all the quadrants.

➤No visible pulsation, dilated veins and localized swellings.

PALPATION

➤Liver , spleen not palpable.

➤No tenderness

CENTRAL NERVOUS SYSTEM EXAMINATION

➤Conscious and coherent

➤Speech : Normal

➤No signs of meningeal irritation

Clinical images

PROVISIONAL DIAGNOSIS : Pyoderma gangrenosum secondary to SLE(?) associated with Anemia secondary to chronic inflammation and Hypotonic hyponatremia .

INVESTIGATIONS

1. Hemogram