Case 5

A 61 year old man with itching all over the body.

Hi, I am R. Ramya Keerthana , 3rd semester medical student.This is an online elog book to discuss our patient's health data after taking his/her consent.This also reflects my patient centered online learning portfolio.

Case Scenario
A 61 year old man came to hospital on 22th August with complaints of itching all over his body since 4 years and shortness of breath in cold climate.

Chief complaints
- itching all over his body since 4 years 
- shortness of breath in cold climate

History of present illness
- patient first developed itchy lesions on both upper limbs and lower limbs 16 years ago

- he then developed itchy skin lesions on back and trunk 4 years ago

- lesions subsided in winter but he had shortness of breath in cold climate 

History of past illness
- he was diagnosed with hyperglycemia 4 years ago for which he was on medication for 20 days after which his blood sugar levels returned to normal and medication was discontinued.

- not a known case of hypertension, asthma, CAD, epilepsy, tuberculosis and cancer.

Drug History
- clobetasol cream 8 years ago
- permethrin, mometasone, ceflox-CF, metron-NF 5 years ago 

Personal History
- married
- normal appetite 
- mixed diet
- regular bowels
- normal micturition 
- no known allergies 

Family History
- no diabetes mellitus 
- no hypertension 
- no heart disease
- no stroke
- no cancer
- no tuberculosis 
- no asthma
- no other hereditary diseases

Physical examination
- no pallor
- no icterus
- no cyanosis 
- no clubbing of fingers
- no lymphadenopathy 
- no edema of feet
- no malnutrition 
- no dehydration 

Vitals
Pulse rate: 72 bpm
Respiratory rate: 18 bpm
BP: 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
- many scaly lesions on all 4 limbs and scalp
- many hypopigmented spots on back and trunk
- subungual hyperkeratosis of great time
- annular plaque and excoriations on buttocks
Medication Chart


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