65Y old male with burning micturition, itchy skin lesions since 1 month

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I have 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.

CHIEF COMPLAINTS :

Patient came with chief complaints of 

     -Burning micturition since 1 month

     -Itchy skin lesions all over body since 1 month

     -Difficulty in urination since 2 weeks.

HISTORY OF PRESENTING ILLNESS 

Patient was apparently alright 1 month back then he developed itchy skin lesions all over body insidious in onset gradually progressive, no aggravating and relieving factors.

Burning micturition since 20 days, insidious in onset gradually progressive

No history of fever, cough, breathlessness

No history of chest pain, palpitations, profuse sweating

No h/o abdominal pain, nausea,vomiting 

PAST HISTORY

History of similar complaints on and off since 6 -7 years and is on medication (apremilast)

Known case of diabetes type 2 and is on regular medication since 15 years

Not a known case of hypertension, asthma, epilepsy, CVA CAD

Occasional alcoholic stopped 30 years ago 

Smokes 20 beedi per day , stopped 6 years ago .

GENERAL EXAMINATION

Patient is conscious coherent cooperative  moderately built and nourished 

Mild Pallor ,No Icterus Clubbing Cyanosis  Edema 

Vitals : 

PR  : 76 bpm

BP : 110/70 mmHg 

RR : 20 CPM

Temperature : 98.7f

Spo2 : 99 %

GRBS : 159mg /dl

SYSTEMIC EXAMINATION

CVS : S1 and S2 heart sounds heard

CNS: NO focal neurological deficits 

RR: BAE Present, normal vesicular breath sounds heard,no adventitious sounds

shape of the chest: normal

trachea appears to be central

Per abdomen: soft, non tender

Skin lesions all over body 

Lesions over scalp 

INVESTIGATIONS 

Provisional diagnosis - 

Chronic kidney disease with chronic plaque psoriasis 

TREATMENT:

1)Inj ceftriaxone 1g iv 12th hourly

2)Tab. Lasix 40mg po bd 

3)Tab metformin 500mg po od

4)Tab tecrin 5mg po od

5)Mommate cream L/a

6)Liquid paraffin L/a twice daily

7)Halox -s lotion L/a twice daily.