GM case 7

Gm-Case 6
Case scenario

Hi, this is P. Vennela, IIIrd BDS. This is an online eblog book to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio. 

                          CASE HISTORY
Chieft complaints:
63 yr old male from pedhevulapalli came to OPD 8 days ago with 
c/o-swelling of face and legs since 1 month
Fever since 2 months. 
History of present illness:
Patient was apparently asymptomatic 2yrs back. First he developed stiffness in his left wrist and then he developed stiffness in his left hand and left leg he has no sensation in his left limb.He immediately reached out to the hospital in miryalaguda and treatment was given accordingly.
After few days of this attack he developed black patches on his hands, abdomen and legs,and then progressed to all over body. Associated with itching and scaling during nights mostly.He has burning and pricking sensation,relieved by medication 
No h/o seasonal variation of itching.H/o of application of luvicinazole,miconazole,clobeterol, salicylic acid, liquid paraffin with no improvement .
He gives a history of fever  associated with chills during morning and rigors, relieved on medication.
History of past illness:
No h/o of similar complaints in the past .
He gives a history of joint pains of hand and feet not associated with morning sickness.
He had an trauma in his left knee 7yrs ago and he was not treated and condition gradually worsened.
He is k/c/o hypertension since 2 yrs
 No history of Diabetes ,leprosy,thyroid,asthma,CAD.
Treatment History
He is on medication for hypertension 
   since 2yrs.
   He is on clopidogril and calcium tablets
   since 2 yrs.
Personal History 
Appetite-Normal
Diet-Vegeteraian
Bowels and micturition-Normal
Addictions- consume toddy occasionally from past 2 yrs he has stopped it. No other addictions. 
 General examination 
patient was conscious and coherent and comfortable. 
Pallor - No
Icteris- No
Cynosis-No
Lymphedenopathy-No
Pedal edema-present. 
Systemic examination 
RESPIRATORY 
Inspection- flat chest with a slight depression in the centre. 
Palpation - bilateral air entry present, normal vesicular breath sounds heard, no adventitious sounds
ABDOMEN
soft non tender , umblicus is everted, no scars and sinuses.
Investigations


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