41 YEAR OLD MALE WITH ITCHING AND SCALING OF SKIN

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CASE:

41 year old male came with the chief complaints of itching and scaling of skin all over the body since the last two months

HISTORY OF PRESENTING 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 but it did not reduce, 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 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, asthama, tuberculosis

Has no history of any previous surgeries

FAMILY HISTORY

His maternal uncle has a history of similar complainfs 

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:

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 daily wakes up at 7 am in the morning and does his morning hygiene routie following which he goes to work if he has or else he stays at home. 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. He falls asleep early in the morning.

MEDICATION HISTORY:

Methotrexate, propysalic ointment, betamethasone, homeopathy and ayurveda since the last 10 years (irregular)

Inj. Dexamethasone/triamsinalone every 3 months since the last 7 years.

GENERAL EXAMIANTION: 

On examination 

Patient 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:

1) CVS:

S1 and S2 heard

No thrills and murmurs

2) 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

3)ABDOMEN;

 flat abdomen, no scars , scaling all over the skin, no hepatomegaly and spleenomegaly

No tenderness present

4)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

Chest x ray:

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