41 year old male with itching and scaling of skin

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R.Navya

Roll No:-112

9th semester

CASE:-

41 year old male came with the 

*Chief Complaints:- 

•Itching and scaling of skin all over the body since the last three months.

*History Of Present 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 it was temporarily relieved on medication. As he was unable to afford the medication he stopped taking medication in between and it recurs when he stops using medication.

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.

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 a local RMP who gave him an injection of dexamethosone and triamsinalone which relieved his symptoms immediately within one hour. Since then he has been visiting the same clinic and has been taking these injections every two to three injections per month since then.

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 walking) 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, asthma, tuberculosis.

•Has no history of any previous surgeries

*Family History:-

His Grand father and maternal uncle has a history of similar complaints over legs.

*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 alcohol since 15 years, drinks everyday for a few weeks and then discontinues for a while.

Consumes 1 packet of tobacco everyday.

*Daily Routine:-

He daily wakes up at 7 am in the morning and does his morning hygiene routie following which he goes to work.He comes in the evening and drinks regularly. He is unable to fall asleep as he feels discomfort and usually peels the scaly skin due to itching.

The patient had to change many occupations over the years due to his health. Initially he was a courier delivery man but had to leave the job as his condition worsened depending on the weather. He is currently a painter. 

He says during work he works for one hour and takes rest for the next 2 hours as he is unable to stand and do the work properly.

*Medication History:-

•Methotrexate, propysalic ointment, betamethasone first 15 years.(irregular) 

•Homeopathy and ayurveda since the last 10 years (irregular).

•Inj. Dexamethasone/triamsinalone every 2-3 months since the last 10 years.

*Clinical Images:-

*GENERAL EXAMINATION:-

*Patient is conscious, coherent, cooperative  

*Pallor present

*No icterus, cyanosis, clubbing, lymphadenopathy, Edema

*Scaly lesions present all over the body

*Vitals:-

•Temperature:101

•BP: 100/70 mm of Hg

•Pulse rate: 96

•Respiratory rate: 24

•GRBS: 96mg/dl

*SYSTEMIC EXAMINATION:-

*CVS:-

•S1 and S2 heard

•No thrills and murmurs

*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

*Abdomen:-

•Flat abdomen, no scars , scaling all over the skin.

•No hepatomegaly and spleenomegaly

•No tenderness present

*CNS:-

•Patient is conscious and alert

•Speech is normal

•Cranial nerves: 1-12 : normal

•Sensory examination: normal

•Motor examinatio: tone: normal 

•Power : 5/5 (normal)

•Reflexes: all reflesxes: +3

*Provisional Diagnosis:-

Erythrodermic psoriasis

*Investigations:-

*HAEMOGLOBIN : 10.1gm/dl

*RFT:

-Creatinine: 0.4md/dl

*ESR: 26 mm/1st hour

*LFT:

-Total bilirubin: 1.05 mg/dl

-Alkaline phosphate: 318 IU/L

-Total proteins: 6.1 gm/dl

-Albumin: 2.5gm/dl

*CBP:-

*CUE:-

*ESR:-

*RFT:-

*LFT:-

*RBS:-

*HbsAg:-

Chest x ray:

2D Echo:

*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