General medicine case discussion

 Medicine case discussion

This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s 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 book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .

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.Tejarshini

Roll no:61

9th semseter

March,31,2022.

41 year old male resident of choutuppal came with chief complaints  of itching and scaling all over the body since 3 months 

HOPI :

The patient was apparently asymptomatic 25 years ago then he had itching and scaling of the skin initially over the scalp and it was slowly progressed to forearms ,face, lower limbs, trunk and back.
It gets aggravated in winter and rainy season
He consulted various dermatologists and was given medication but it did not reduce. So he tried so many different medications and ayurveda 

2011:
 He went to RMP and injection(dexamethasone and triamcinolone) was given and his condition was relieved for 6months so he got married and after 3- 4 months of his marriage , once again he developed itching and scaling all over the body.

During this time he was working as a courier delivery man and he was exposed to heavy rain and aggravated his condition. So he went to same doctor , injection of dexamethasone and triamcinalone was given which relieved his symptoms immediately within one hour.

Since then he was taking one injection for every 2-3months.

2021 :  in December he had infection at injection site( gluteal region on right side)and there is yellowish discharge from the site . it got relieved spontaneously .

 He also had swelling of lower limbs which was pitting type  associated with pain and .he visited local doctor . And received medication which got relieved.

Then he continued his injections but this time injection didn’t work and  he also had weight loss (15 kgs) .

2022 : (March) :10 days ago he visited a local doctor due to severe itching and scaling then he was referred to our hospital.

H7

PAST HISTORY:

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

 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 family history

His maternal uncle have similar complaints .

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:

Appetite: decreased since the last 3 months.

Diet: Vegetarian since 10years.

Sleep: inadequate due to itching he won't sleep.

Bowel and bladder : regular

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

Consumes 1 packet of tobacco everyday.

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:

Patient is conscious, coherent, cooperative . 

Moderately built and Moderately nourished

Pallor present 

No icterus, cyanosis, clubbing,  Generalized lymphadenopathy,pedal Edema

Vitals: 

Temperature:101°F

BP: 100/70 mm of Hg

Pulse rate: 96 beats/min

Respiratory rate: 18breaths/min

GRBS: 96mg/dl 

SYSTEMIC EXAMINATION:

1) CVS:

S1 and S2 heard

No thrills and murmurs

2) RESPIRATORY SYSTEM:

Inspection: bilaterally symmetrical chest with equal expansion on both sides.

Palpation: trachea centrally placed, bilateral expansion of chest is equal

Percussion :Resonant note heard over all areas

Ausculation: vesicular breath sounds heard in all areas

3)ABDOMEN;

 flat abdomen, no scars , scaling all over the skin, no hepatomegaly and splenomegaly

No tenderness present

4)CNS:

Higher mental functions intact

Reflexes present.

Investigations:

24/03/2022:

HIV:Negative

25/03/2022:

29/03/2022:

Color Doppler:

Provisional Diagnosis:

ERYTHRODERMA PSORIASIS

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