18 year old female presented with white lesions

 

 Medicine Case

 Discussion

This is an online e logbook to discuss our patients deidentified health data shared after taking her/guardian's signed informed consent

Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs

This E log also reflects my patient centre’s online learning portfolio and valuable inputs on the comment box is welcome.

S.Kavya sree 

 1701006164

Case discussion

18 year old female patient who is resident of nalgonda presented with the complaints 

- white lesions over both upper and lower limbs, trunk, face and right ear since 10 year

History of presenting illness

 Patient was apparently asymptomatic 10 years ago then she developed white lesions over both upper and lower limbs , face ,trunk and right ear . The lesions progressively increased to the present condition

 Patient gave history of usuage of unknown oral and topical medications on and off since 8 years . 

No history of itching over lesion 

No history of allergies

 No history of chemicals application

 No history of similar white lesions in the family members

 

 

 

 

Past History

No history of diabetes,hypertension, asthma, epilepsy, tuberculosis.

Personal history 

Diet mixed, appetite normal, bowel and bladder regular, sleep adequate, no addictions and allergies

Family history 

No similiar lesions in the family members,

 no history diabetes, hypertension, tuberculosis, asthma in the family

GENERAL EXAMINATION

She is examined in a well lit room and after adequate exposure.
She is conscious, coherent, cooperative and well oriented to time ,place and person.
She is moderately built and moderately nourished.

VITALS 

Temperature - Afebrile

Pulse rate - 88bpm

RR -18 CPM

BP:110/80mmhg ,measured in sitting position in left upper arm

SYSTEMIC EXAMINATION

*RS: BAE - present,no added sounds

*CVS;S1,S2 heard,no murmurs 

*PER ABDOMEN:soft and non tender,No organomegaly.

*CNS: Intact

Cutaneous Examination

Multiple Depigmented macules noted over all four extremities

single white lesion on posterior trunk, scalp also over right eye and right ear. 

*LEUKOTRICHIA present on lower limb macules

 

 

Provisional Diagnosis - vitiligo vulgaris

 

Treatment - Topical steroids - mometasone

Topical immunomodulators  tacrolimus ointment

Advice to the patient - protection of patches from excessive sun exposure with clothing or sunscreen to avoid sunburns