General medicine blog-1

Hi, I am N.Rohith (Roll no:79) 3rd sem medical student. this is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.

A 66 yr old male patient farmer by occupation with itching all over his body since 5 years.pustules since 3 days.

Chief complaints 

The patient came to the hospital 8days back with chief complaints of excessive itching with blisters all over his body.

History of present illness

Patient is suffering from itching from past 5 years

and took black magic treatment for painful lesions on both legs,chest and both arms

History of past illness

In the past due to lack of micturation the patient had undergone an surgery.

The patient  is also diagnosed with hypertension 2yrs back and diabetes 5 years backs.

The patient is not a known case of asthma and

tuberculosis. 

Personal history 

Diet:mixed

Appetite:normal

Sleep:normal

No known allergies 

General examination 

No pallor 

No icterus 

No cyanosis 

No clubbing of fingers

No lymphadenopathy 

No pedal odema 

SYSTEMATIC EXAMINATION:

B. CARDIO VASCULAR SYSTEM

1. Thrills No 

2. Cardiac Sounds

3. Cardiac murmurs No 

C. RESPIRATORY SYSTEM

1. Dyspnoea - No

2. Wheeze - No 

3. Position of Trachea - Central

4. Breath Sounds - Vesicular

5. Adventilious Sounds - No

D. ABDOMEN

1. Shape of abdomen - Scaphoid 

2. Tenderness - No

3. Palpable mass - No 

4. Hernial Orifices Normal 

5. Free Fluid No 

6. Bruits No 

7. Liver - Not palpable

8. Spleen - Not palpable 

9. Bowel sounds -Yes

Test reports

Probable diagnosis : bullous pemphigoid

Treatment

Dolo 650mg 

Amoxiclav 625mg

Fiduc cream

Atarax 10mg

Aceclo P