GM case : 03

Hi , I am Pranavi Thavidaboina 3rd year dental student . This is online elog book to discuss my patient health data shared after taking his/her consent . This also reflects my patient centered online learning portfolio .

The patient’s consent was taken verbally prior to history taking and examination of his/her condition. 

CASE SHEET :

This is a case of 35 years female with exfoliative dermatitis and skin problem.

CHIEF COMPLAINTS :

Patient came with itching lesions all over her body associated with burning sensation , high fever ( 10 days back ) , dandruff along with hair loss .

HISTORY OF PRESENT ILLNESS : 

Patient was apparently alright 1 month back , her present complaint started as itching , redness over her thighs ( sudden onset -10 days back ) . Later progressed to abdomen , 2 days later spread all over her body . Loosely adherent scales ( exfoliative skin ) is present and hand-full of scales are lost everyday with burning sensation and dryness of the skin . No joint pains , low grade fever ( sudden onset ) with raise in temperature in the evening . No cold or cough.

HISTORY OF PAST ILLNESS : 

Patient suffered with similar complaints mentioned above , was diagonised with Psoriasis 10 years back and was under medication since then . Since 10 years onwards on and offset of disease with 2 to 3 episodes per year . Under surgery for CAD ( coronary associated disease ) 9 years back under medication for 5 years and stopped later .

PERSONAL HISTORY :

Married 

Occupation : Housewife

Appetite : Normal

Food : mixed 

Bowels : normal

Known Allergies : Nil

Habits/Addictions : Nil . 

FAMILY HISTORY : Nil .

GENERAL EXAMINATION :

Cyanosis : No

Clubbing : No

Lymphadenopathy : No

Oedema : Yes ( pedal oedema )

Pallor : No

Icterus : No

Malnutrition : No

Dehydration : No 

Consciousness : In conscious .

VITALS :

Temperature : 98.6F

Pulse : normal

Respiratory rate : 15 cycles per minute

BP : 110/70 mm/Hg .

PROVISIONAL DIAGNOSIS : Chronic Psoriasis .

QUESTIONS : 

Does this skin condition indicate any underlying systemic problem ?