MCTD
This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission. 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 treatment plan
Case scenario:
A 35 yr old male who is tractor driver came to opd with cheif complaints of itchy skin lesions all over the body since 8 months
History of presenting illness:
Patient was apparently asymptomatic 8 months back, then he developed small papules over the chest after which it transformed into erythematous scaly plaques first on nose and cheek then over the entire face, neck, back, hands and legs.
H/o itching over the papules
H/o photosensitivity present (itching,burning sensation when exposed to sunlight)
C/o tenderness in wrist joint metacarpophalangeal joint and inter phalangeal joint.
H/o fever 4episodes in last 8 months last episode 25 days back.Fever last for 1 day and relieved after taking medication
H/o oral ulcers on hard palate since 15 days
No chest pain,sob, palpitations
No abd pain, nausea, vomiting
No decreased or increased urine output
Past History:
H/o cerebro vascular accidents, left upper limb and lower limb weakness and slurred speech 10 yrs back
H/o appendectomy 8yr ago
Not a k/c/o DM, HTN, TB, Asthma, Epilepsy
Treatment History:
Surgeries: appendectomy 8yrs back
Personal History:
Diet -mixed
Appetite- Normal
Bowel and bladder movements - regular
Addictions- alocohol (toddy drinker since 20yrs)
Tobacco- Beedi 🚬 (15/day)smoker since 25 yrs
No allergies
Family History:
Not relevant
Physical Examination:
General examination:
No pallor
No icterus
No clubbing
No cyanosis
No lymphadenopathy
No pedal edema
No malnutrition
No dehydration
Vitals:
Temperature:98.7F
Pulse rate : 78 beats/min
Respiratory rate:12/ min
Bp:110/70
Systemic Examination:
CVS:
no thrills
S1 and S2 heard
No murmurs
Respiratory examination:
No dyspnoea
No wheeze
Position of trachea - central
Breath sounds -vesicular
Abdominal examination:
Shape of abdomen scaphoid
No tenderness
No palpable mass
No hepatosplenomegaly
No bowel sounds
Central nervous system
Conscious, coherent
Speech normal
No signs of meningeal irritation
No neck stiffness
No kernigs sign
Cranial nerves
Motor and sensory system normal
Provisional diagnosis
MCTD ( mixed connective tissue disorder)
Treatment
T. Prednisolone 10mg po/od
T. HCQ 200 mg po/bd
T. PCM 650 mg po/bd
Mucopain gel L/A /tid
T. Pregabalin 75mg po/HS
Suncros aquagel spf 50 L/A
Momate -F cream L/A on fingers
T. Benfomet plus po/od
Nicotine gums 2mg/bd
Comments
Post a Comment