35 years male with itchy skin lesions

This is an 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.

Chief complaints:-

Itchy skin lesions all over the body since 8 months 

History of present illness:-

Patient was apparently alright 8 months back then he developed small papules over the cheek after which it transformed into erythematous scaly plaques first on the nose and cheek then over the entire face,neck,back,hands and legs.

H/o itching over the plaques

H/o photosensitivity 

C/o Tenderness in wrist joint, metacarpophalangeal joint,interphalangeal joint 

H/o fever 4 episodes in last 8 months,last episode 20 days back.fever lasts for one day releived after taking medication.

H/o oral ulcers on hard palate since 10days

No chest pain,sob, palpitations

No abdominal pain,nausea vomiting 

No increased or decreased output 

 PAST HISTORY:

H/o cva, left UL ,LL weakness and slurred speech 10 years back 

H/o apendectomy 8 years back 

Used ayurvedic medicine  1 month back for 15 days.

 Not a known case of diabetes mellitus, hypertension, tuberculosis, asthma, epilepsy

Family history:- 

not significant

Personal history:- 

Appetite:- decreased since 3 days

Diet:- mixed

Sleep :- adequate

B& B :- regular 

Addictions :- toddy drinker since 20 years 

Bedi smoker since 25 years(15 per day)

General examination:- 

Patient is conscious, coherent, cooperative well oriented to time place and person .

Moderately built, moderately nourished

Pallor:- absent 

Icterus:- absent 

Cyanosis:- absent 

Clubbing:- absent

Generalized lymphadenopathy:- absent

Bilateral pedal edema :- absent 


Vitals:- 

Bp:100/70 mmhg 

Pulse rate:-80 bpm 

RR:- 18 cycles per min

Temp :- afebrile

Systemic examination:-

Cvs :- s1,s2 heard no murmurs

Cns :- no focal neurological deficits 

Abdomen :- soft ,non tender 

Rs:- BAE present 


Investigations:- 

5/4/2023





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