23 year old male
July 25 2022
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CASE OF MULTIPLE SKIN LESIONS
A 23 year old lady , psychologist by occupation resident of nalgonda came to opd with c/c of painful skin leisions over the upper and lower limbs and back of trunk since 8 months
HISTORY OF PRESENT ILLNESS:
Patient was apparently assymptomatic 8 months back she developed multiple red lesions on both upper limbs not associated with burning or itching after 1 week she developed itching and burning then she consulted local doctors who prescribed some medications but leisions didn't subsided so she referred to another hospital Where she diagnosed HENOCH SCHOLEIN PURPURA
EXAMINATION:
GENERAL PHYSICAL EXAMINATION:
patient is conscious, coherent,cooperative and moderately built and moderately nourished
VITALS:
→ patient is afebrile
→ BP-110/80 mm Hg
→ PR-70 bpm
→ RR-16 Cpm
✓SpO2- 98%
✓GRBS - 122gm/dl
No Pallor, Icterus, Cyanosis, clubbing, Odema, lymphadenopathy.
ON INSPECTION:
red erythematous lesions Over Hands, legs, Palms and Soles including Web Spaces
CNS EXAMINATION:
- Higher mental functions-normal
- Cranial nerves- intact
- Sensory system- normal
- Motor system- normal
- Meningeal signs- absent
- Cerebellar signs- absent
CVS EXAMINATION:
INSPECTION:
No scars sinuses and engorged ve
No visible pulsation
PALPATION:
apical impulse : heard in fifth inter coastal spac
ASCULTATION:
S1 and S2 heard
No murmurs
RESPIRATORY SYSTEM EXAMINATION:
INSPECTION OF UPPER RESPIRATORY SYSTEM:
oral cavity- normal
Nose- normal
Pharynx- normal
LOWER RESPIRATORY TRACT:
INSPECTION:
trachea: central
Symmetry of chest : symmetrical
Movement: B/L symmetrical expansion of chest respiration
No scars, engorged veins or sinuses.
PALPATION:
All inspectory findings are confirmed by palpation.
Trachea: central - confirmed by three finger test.
Assessment of anterior and posterior chest expansion- B/L symmetrical expansion of chest.
No chest wall tenderness
Vocal fremitus- normal
PERCUSSION:
done in sitting position
Resonant
AUSCULTATION:
Vesicular breath sounds heard
Bilateral air entry present
No added sounds
ABDOMINAL EXAMINATION:
INSPECTION:
Shape : elliptical
Quadrants of abdomen moving in accordance with respiration.
Umbilicus- central and inverted
No scars sinuses or engorged veins
PALPATION:
No tenderness
No organomegaly
PERCUSSION:
tympanic
ASCULTATION:
Normal
No organomegaly , no tenderness.
INVESTIGATION REPORTS:
PROVISIONAL DIAGNOSIS: - HENOCH SCHONLEIN PURPURA ( Leucocytoclastic Vasculitis)
TREATMENT:
At present patient is using:
Tab. Dapsone 100mgS
Syruporofer 5mlT
Tab Shelcal
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