A 61 yr old male with itching all over the body

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 24 August 2022 

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment .

Khushi Tulsyan

Roll no. 75


A 61 yr old male farmer by occupation resident of Bengal presented to opd with chief complaints of  itching all over body since 20 yrs. 


HISTORY OF PRESENTING ILLNESS-

Patient was apparently asymptomatic 20 yr ago. Then he developed itching on his forearm and leg below the knee which was gradual in onset slowly progressive. 

Itching was occasional and is aggravated on working under sun/warm temp due to sweat. 

4 yrs back patient had an increase in itching after he took homeopathy medicine (reaction observed on 2 nd day - but still patient continued it for 20 days) and also started on his back and on chest and had few eruptions on his hand and he went to local rmp time to time and there was decrease in itching for time being and would increase as soon as he stops applying the ointment.

No history of any pain or loss of sensation in the affected area. 

No history of joint pain. 

There is an history of exposure to animals (goat and bull) on a daily basis as he is a farmer. 

Patient is known to be taking repeatedly ayurvedic and allopatheic treatment. 


PAST HISTORY-

Patient is a known case of Diabetes since 4 yrs which was diagnosed accidentally and he is not taking any medicines/drugs to cure that and he seems to manage it conservatively. 

Not a known case of hypertension, aastha, leprosy, epilepsy, cad, ckd. 


TREATMENT HISTORY-

Previous topical treatments for on and off for 20 yrs which the patient doesn't remember. 


PERSONAL HISTORY-

Diet - Mixed

Appetite - Normal

Bladder and bowel - Regular

Sleep - Adequate

Allergies - None

Addictions - Smoking since 20 yrs of age but he stopped it 4 yrs back. 


FAMILY HISTORY-

No known family history of any skin disease or any autoimmune conditions. 

GENERAL EXAMINATION-

Patient is conscious coherent and co operative well oriented to time place and person. 

Patient was examined in a well lit room and consent was taken.

Vital -

PR-75bpm

BP-110/70

RR-16cpm

SPo2-98%

Temp-Afebrile

Pallor - Absent

Icterus - absent

Clubbing - Absent

Cyanosis- Absent

Lymphadenooathy- Absent

Edema - absent


SYSTEMIC EXAMINATION-

CVS - S1, S2 heard

Resp - NVBS

CNS - NFD

Per Abdomen - Soft and non tender

Skin - 

Multiple well defined plaques with scaling on 4 extremities and multiple well defined hypopigmented plaques over back. 


During hospital stay-
There was increase in his rashes due to sweat. 
PROVISIONAL DIAGNOSIS-

Chronic Psoriasis with Taneia corporis infection

PLAN OF CARE-


Liquid parrafin for dry skin
Lulicaonazole for taneia infection
Clacitriol and clobetasol propionate for psoriasis

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