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

This an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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.





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