Pre- final medicine case discussion
I’ve 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 diagnosis and treatment plan
K.shirisha
Rollno;60,
9th semester
Case discussion ;
A 41 year old male patient painter byoccupation since 7 years.resident of choutuppal came to the hospital .
Chief complaints;
Itching and scaling of skin all over the body since 3 months
History of present illness;
Timeline events;
The patient was apparently asymptomatic 25 years ago then he had a itching and scaling of the skin . which was initially overthe scalp and it was slowly progressed to fore arms ,face, lower limbs, trunk and back.
Aggrevated on winter and rainy season
First he consulted local doctor .and treatment was taken.of unknown medication.which was not getrelieved.after that he consulted a dermatologist in Aurangabad . doctor told that his condition was due to stress,and tension.he was given medication.with in 6 months it got subsided.
In2011;
He got married that his condition got relieved. After 4 months of his marriage. once again he developed itching and scaling all over the body.consulted various dermatologists . Doctors said reason was due to tension,stress.and it will be a life long. recieved various treatments including ayurvedic medicine ( plant medicine).which was reducing for sometime and again his condition got recurring when he stops medication.
Before paint working .he has been working as a courier. one day,he was exposed to heavy rain . His itching and scaling got aggrevated.he visited local rmp doctor taken medication like dexamethasone and triamcinolone which got releived with in one hour.
Since 7-8 years he was recievingthis injections every3 months.
2021 : in December he had infection( abscess) over injection site( gluteal region on right side)and the yellowish discharge was came out of swelling .a pus was drained and it wasrelievedspontaneously. due to infectionhe had weight loss of(15 kgs) .
After 3months
hehad swelling over lower limbs which was pitting type associated with pains and .he visited local doctor . And received medication which got relieved.
2022 : (March)
10 days ago he visited local doctor due to severe itching and scaling. Due to which his condition wasdeteriorating and not getting relievedon injections . thenhe wasreferred to our hospital for further evaluation.
Past history;
The patient was not conscious, at the time of presentations.
Now she was conscious, coherent and cooperative
Moderately built and moderately nourished.
Pallor: present
Icterus absent
Cyanosis absent
Clubbing absent
Edema absent
Lymphadenopathy absent
Vitals;
Temperature 98.4°F
Blood pressure 130/70mmhg
Heart rate 80bpm
Respiratory rate 18cpm
Systemic examination;
Examination of skin;
Scaly lesions all over the body;
Per abdomen;
Inspection
Shape ; normal
Umbilicus : central
Movements equal on respiration
No visible pulsations, engorged veins,no visible peristalsis
Skin over abdomen ; normal
Palpation; soft,non tender
No organomegaly
Percussion; resonant note heared
Auscultation : bowel sounds were heared
Respiratory system ;
Inspection ;
Inspection of upper respiratory tract;
Oral cavity ; normal
Nose: no dns,polyp
Pharynx; normal
Lower respiratory tract;
Position of apex beat ; left 5ics 1cm medial to mid clavicular line
Symmetry of chest : symmetrical and elliptical
Movements of chest ; normal
Position of trachea ; midline
Bilateral air entry present
Palpation:
No tenderness over chest wall,no crepitations,no palpable added sounds,no palpable pleural rub
Percussion;
Resonant note heared
Auscultation; normal vesicular breath sounds heared, bilateral air entry present
Cardiovascular system;
2d echo;
Complete urine examination;
Blood sugar random; 102mg/dl
Liver function tests;
Renal function tests;
Hbs ag ; negative
Erythrocyte sedimentation rate; 26
TREATMENT:
- IVF -NS, RL- 75ml/hr with 1amp of optineurin IV OD
- INJ.Thiamine 1amp in 100ml NS IV BD
- liquid paraffin+glycerin+water (apply in equal proportions) three times/day
- tab shelcal OD
- Tab. Dolo 500mg po sos
- Tab. Folic acid 5mg po
- protein x powder with milk
- high protein diet
- tab MVT OD
- tab pregabalin 75mg + tab methylcobalamine 750mcg
- Tab. Lorazepam 2mg po sos
- Fudic cream
- Tab. Escitalopram 5mg OD night
- Tab. Clonazepam 0.5mg
- tab methotrexate 15 mg once weekly for 6 weeks
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