Hi, I am Manasvi Peddineni, 3rd sem medical student.This is an online elog book to discuss our patients health data after taking their consent. This also reflects my patient centered online learning portfolio.
Case Scenario:
A 61 year old male has come the hospital with complaint of itchy lesions over both lower limbs since 16 years all over his back and trunk since 4 years.
Chief Complaint:
- itching all over body since 4 years
- shortness of breath in cold climate
- patient was apparently asymptomatic 16 years ago when he first developed itchy lesions on both upper limbs and lower limbs
- 4 years ago he developed itchy skin lesions on back and trunk
- the lesions subsided in winter but he had shortness of breath in cold climate
- he was diagnosed with psoriasis after visiting various clinics in his home state of West Bengal
History of past illness
- 4 years ago he was diagnosed with hyperglycemia for which he was given Oral Hypoglycemic Agents for 20 days after which his blood sugar levels returned to normal and medication was stopped
- not a known case of hypertension/ asthma/ CAD/ epilepsy/ thyroid disorders
Personal History
- married
- normal appetite
- mixed diet
- regular bowels
- normal micturition
- no known allergies
- no known addictions
Family History
- no diabetes mellitus
- no hypertension
- no heart disease
- no stroke
- no cancer
- no tuberculosis
- no asthma
- no other hereditary diseases
Drug History
- clobetasol cream 8 years ago
- permethrin, mometasone, ceflox-CF, metron-NF 5 years ago
Physical Examination:
- height: not taken
- weight: not taken
- BMI: not taken
- no pallor
- no icterus
- no cyanosis
- no clubbing of fingers
- no lymphadenopathy
- no edema of feet
- no malnutrition
- no dehydration
Vitals
-pulse: 72 bpm
- respiratory rate: 18 bpm
- blood pressure: 120/80 mm Hg
- GRBS: 134 mg/dl
- SPO2: 97% at RA
- temperature: afebrile
Systemic examination
Cardiovascular System
- no thrills
- cardiac sounds S1 and S2 heard
- no cardiac murmurs
Respiratory System
- no dyspnea
- no wheezing
- trachea position: central
- breath sounds: vesicular
Abdomen
- shape: obese
- no tenderness
- no palpable mass
- no bruits
- no free fluid
- hernias orifices: normal
- liver: not palpable
- spleen: not palpable
- no bowel sounds
- genitals: normal
- speculum examination : normal
- P/R examination : normal
Central Nervous System
- conscious
- normal speech
- no neck stiffness
- no Kernig's sign
- cranial nerves: normal
- sensory : normal
- motor: normal
- reflexes: present
Skin
- multiple well defined plaques noted with scaling over all four limbs
- multiple well defined hypopigmented macules noted over trunk and back
- scaling noted over scalp
- subungual hyperkeratosis of great toe
- well defined annular plaque and excoriations on buttocks
Treatment:
- tab Atrax 25mg
- Sorvate - C ointment
- liquid paraffin
- lucifin cream