General medicine-Prefinal practical

A.Bhavani ,roll.no-150,MBBS 9th semester 

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.

CASE:

41 year old male came with the chief complaints of itching and scaling of skin all over the body since the last three months

HISTORY OF PRESENTING ILLNESS

The patient was apparently asymptomatic 25 years ago then he developed itching and scaling over the scalp which then spread to his face, shoulders, chest, abdomen, back and lower limbs involving the whole body. 

He went to a dermatologists then and was given medication but it did not reduce, so over the years he has tried different medications including  homeopathy and ayurveda and then the itching and scaling reduced with recurrent episodes over the years.

It worsened during the winter season.

10 years back when went an RMP and he gave him some medication and he felt better until 7 years ago while he was working as a courier delivery man he was exposed to heavy rain which increased his condition he immediately went to the same RMP who gave him an injection of dexamethosone and triamsinalone which relieved his symptoms immediately within one hour.

 He has been visiting the same clinic and has been taking these injections every two to three months since then for the last 7 years. 3 months ago he developed an infection at the injection site (right thigh).

It progressed with a yellow discharge (pus) coming from the site which then reduced spontaneously without any medication.

 Then he continued the injections given by the rmp but this time the itching and scaling did not reduce. He has also lost 15 kgs in this period.

He also has weakness (unable to stand for longer periods, pain in legs after long-standing) since 3 months and pedal edema since three months which was of pitting type. 

Since his health has deteriorated in the last 3 months he went to a doctor 7 days ago and then was referred to our hospital for further testing.

PAST HISTORY:

He is not a known case of diabetes, hypertension, asthama, tuberculosis

Has 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

His maternal uncle has a history of 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:

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: 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 EXAMIANTION: 

On examination 

Patient is conscious, coherent, cooperative went oriented to time place and person 

Pallor present

No icterus, cyanosis, clubbing, lymphadenopathy, Edema

Vitals: 

Temperature:101

BP: 100/70 mm of Hg

Pulse rate: 96

Respiratory rate: 24

GRBS: 96mg/dl 

SYSTEMIC EXAMINATION:

1) CVS:

S1 and S2 heard

No thrills and murmurs

2) RESPIRATORY SYSTEM:

Inspection: no scars, equal bilateral chest expansion,

Percussion: resonant in all areas

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

Ausculation: vesicular breath sounds heard in all areas

3)ABDOMEN;

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

No tenderness present

4)CNS:

Normal higher motor functions 

No focal neurological deficits 

Clinical pictures  

 

Provisional diagnosis:

Erythrodermic psoriasis 

Investigations: 

ESR: 

Complete urinalysis : 

Complete blood picture:

Blood sugar random: 

Renal function tests:

Liver function tests:

HBs-Ag rapid:

Chest X-ray:

TREATMENT:

1) liquid paraffin+glycerin+water (apply in equal proportions) three times/day

2)tab atarax 25mg OD 

3) tab shelcal OD

4)protein x powder with milk

5) high protein diet

6) tab MVT OD

7) tab pregabalin 75mg + tab methylcobalamine 750mcg