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;

No history of diabetes, hypertension, asthama, tuberculosis

 no history of any previous surgeries

He has a ear piercing done on left ear as he was told that it would reduce his condition. 

Family history;

Significant -his maternal uncle have similar complaints .over scalp and limbs.

Occupational history;

He has been changing his works due to his condition.

He first was a delivery person in Hyderabad then due to marriage he had to come to his hometown where he went to various companies but couldn’t tolerate the chemicals due to his condition and rules of the company. He finally started working as a painter since 5 years 

Personal history;

Diet: vegetarian since the last 10 years

Appetite: decreased since the last 3 months

Sleep: inadequate as he stays awake at night due to the itching 

Bowel and bladder : regular

Addictions: chronic alcoholic since 15 years. drinks 90ml of alcohol daily since 15 years, drinks everyday for a few weeks and then discontinues for a while and then starts again. 

Last drink 5days ago consumed 12 units of alcohol

Tobacco chewer since 15 years.

Consumes 1 packet per day

Medication history;

Methotrexate, propysalic ointment, betamethasone, homeopathy and ayurveda since the last 10 years (irregular)

Inj. Dexamethasone/ triamcinolone every 3 months since the last 7 years.

General examination;

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;

Clinical images 

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;

Inspection;

Position of trachea ;midline

No visible pulsations,no raised jvp

Precordial bulge : absent

Shape of chest; bilaterally symmetrical

Apex beat ; left 5th inter costal space1cm medial to mid clavicular line

Palpation; no palpable thrills,parasternal heaves are palpable

Percussion ; 

Auscultation; S1,S2 heart sounds are heared , no added murmurs,

Central nervous system : 

 

Higher mental functions : 

Level of consciousness: normal

Speech : normal

No meningeal signs

Cranial nerves ; intact

Investigations;

Chest x ray

No evidence of pulmonary, pleural,cardiac pathology is noted

2d echo;

Hiv test; non reactive

Complete urine examination;

Complete blood picture;

Hemoglobin; 10.1 g/dl ( anemia)

Blood sugar random; 102mg/dl

Liver function tests;

Alkaline phosphate; 315 IU/L (elevated)

Total bilirubin; 1.05mg/dl

Total proteins; 6.1gm/dl

Albumin; 2.5 gm/dl

Renal function tests;

Creatinine; 0.4 mg/dl( decreased)

Hbs ag ; negative

Erythrocyte sedimentation rate; 26

Elevated

Provisional diagnosis;

Erythrodermic psoriasis associated with

Alcohol dependence syndrome and tobacco dependence syndrome.

Adjustment disorder, iron deficiency anemia.

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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