E log of medicine case

 NOTE :"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 patients clinical problems with collective current best evidence based inputs"

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. 

 

CASE REPORT :

A 46 year old male came to the OPD with complaints of burning sensation of  foot bilaterally  since 6 months

1.COMPLAINTS AND DURATION

-Not associated with  pedal edema, tingling/ numbness

-No slippage of foot

-Also not associated with tingling and numbness /hyperpigmentation of skin

-History of recurrent episodes of running nose, soar thorat, cough (may be due to allergic rhinitis)

-He had history of trauma to left leg - erythematous patch on left leg - subsided by itself.

2.HISTORY OF PRESENT ILLNESS

Followed by itchy lesions of dorsum of foot bilaterally. 

-Hyperpigmented lesions on both foot with lichenification of right foot was seen

3.HISTORY OF PAST ILLNESS

Not a k/c/o - HTN/DM - 2/TB/Epilepsy/CVA

4.TREATMENT HISTORY

Hypertension - No

CAD- No

Asthma- No

Tuberculosis - No

Antibiotics-No

Hormones-No

Chemo/radiation - No

Blood transfusion - No

Surgeries - No

Others - No

5.PERSONAL HISTORY 

-He is Married

-Appetite is normal

-Non vegetarian 

-Bowels are regular 

-Micturition - Normal

-No known allergies 

-No habits or addictions

6.FAMILY HISTORY:-

No family history of diabetes, hypertension, heart disease, stroke, cancers, tuberculosis, asthma

PHYSICAL EXAMINATION :

A) General Examination - 

On examination patient was conscious,coherent and cooperative

 - No signs of pallor, icterus, cyanosis, clubbing of fingers, toes, lymphadenopathy, oedema of feet, malnutrition, dehydration. 

VITALS - 

Temperature - Afebrile

Pulse rate - 70bpm/min

Respiration rate - 12cpm

Bp - 140/100 mm of Hg

Spo2 at room air 99%

GRBS-109mg%

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM

-No Thrills

-Cardiac sounds - s1 and s2 heard

-No Cardiac murmurs

RESPIRATORY SYSTEM 

-No Dyspnoea

-No Wheeze

-Position of trachea is Central

-Breath sounds are Vesicular 

-No Adventitious sounds 

ABDOMEN 

-Shape of abdomen is obese

-No Tenderness 

-No Palpable mass

-Hernial orifices are normal

-Free fluid - No

-Bruits - No

-Liver is not palpable 

-Spleen is not palpable

-Bowel sounds present

-Genitals are Normal

CENTRAL  NERVOUS SYSTEM

-Level of consciousness :patient is conscious /alert

-Speech is Normal 

-Signs of Meningeal irritation:

-No Neck stiffness and kernings sign

-Cranial nerves, Motor system, sensory system, glassgow scale 15/15

PROVISIONAL DIAGNOSIS:

PERIPHERAL NEUROPATHY 

LICHEN SIMPLEX CHRONICUS 

INVESTIGATIONS :

Fasting blood sugar :

Complete urine examination :

Blood urea:

Serum creatinine :

Serum electrolytes :

Post lunch blood sugar :

ECG:

Glycated hemoglobin :

Cross consultation referrals :

To department of ENT

To department of psychiatry 

To department of Dermatology 

Cross consultation notes by department of dermatology :

This is a case of 46 year old male patient with itching over the both feet since 3 years. 

-No history of  medication taken. 

-History of similar complaints in the past left leg area. 

-Intially lesions were erythamatous papules later progressed to present condition. 

-History of oozing present, no winter aggravation, history of atopy +

-No family history 

-No other comorbidities 

-Occupation - farmer 

-On examination - few well defined polycised hyperpigmented scaly plaques noted over both feet. 

-Lichenified plaque note over right foot. (6×6 cm) 

Diagnosis : LICHEN SIMPLEX CHRONICUS

TREATMENT : CLOPS cream L/A B/D×2 weeks (M), (N) 

Tab. TECZINE 5mg O/D 2 weeks (N) 

Cross consultation notes by the department of ENT :

This is a case of 46 year male with burning sensation of feet and scaly plaques on the feet diagnosed as lichen simplex Chronicus.

-patient is complaining of paroxysmal sneezing and watery nasal discharge on exposure to dust or cold. 

-History of recurrent URTI +. 

-History of 2-3.drops of nasal bleed this morning. 

-No history of nasal obstruction associated with itching sensation in the nose. 

-No history of facial heaviness or postnasal discharge. 

-On examination pt is conscious, cooperative 

HR-64bpm

Bp - 160/110 mmHg

-On examination of nose external framework, vestibule, columella are normal 

-Mucosal trauma on either side of septum(? Finger nail trauma) 

-Mucoid discharge + in the left nasal cavity

-Floor normal. 

-On examination of PNS :no facial assymetry, infra orbital margins - sharp

No local rise of temp

No sinus tenderness 

-On observation of oral cavity dental carries positive. 

-On examination of Oropharynx - posterior pharyngeal Wall 

congested and granular 

-On examination of  ear

Pinna : right and left normal

EAC : normal

Tympanic membrane : right ear is thinned out intact distorted cone of ligh

Left ear is Dull, COL - ve

DIAGNOSIS : allergic rhinitis 

TREATMENT : DUONASE nasal spray 2 puffs 1 month 

SALINE nasal drops 5 days 

Steam inhalation 3-4 times per day 

CLINICAL FINDINGS:-

46/M was brought to casualty with complaints of burning sensations in the feet (bilateral). It was not associated with pedal oedema, tingling/numbness, hyperpigmentation of the skin. There was no slippage of the foot. There was history of recurrent episodes of running nose, sore throat, cough, possibly due to allergic rhinitis.Also history of trauma to the left leg, erythematous patch was seen on the left leg which subsided by itself. History of oozing is present. This was followed by itchy lesions of dorsum of feet (bilateral). Hyperpigmented lesion on both feet with lichenification of right foot were seen.

Personal History: Diet is mixed. Appetite is normal. Sleep is adequate. Micturition is normal. Bowel movements are regular. No habits/addictions.

Examination: Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis, lymphadenopathy, clubbing, oedema.

Vitals: Temperature: afebrile

Pulse Rate: 70bpm

Respiratory rate: 12 breaths per minute

BP: 140/100 mm of Hg

SPO2: 99%

GRBS: 109mg%

CVS: S1, S2 heard, no murmurs

Respiratory system: No dyspnoea, position of trachea is central, breath sounds are vesicular.

Abdomen: shape of abdomen is obese, bowel sounds heard, genitals are normal.

CNS: The patient was conscious and alert.

Investigations:-

   Fasting blood sugar-92mg/dl (70-110)

   Serum creatinine-1.1mg/dl (0.9-1.3)

   PLBS-117mg/dl (0-140)

   Serum electrolytes- Na: 132mEq/L (136-145), K: 4.3mEq/L (3.5-5.1), Cl: 106mEq/L (98-107)

   Blood Urea- 16mg/dl (12-42)

   CUE- normal

Diagnosis:- Peripheral neuropathy, Lichen Simplex Chronicus