41 years old Male with PSORIASIS

This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent.



Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.



This E-blog also reflects my patient's centred online learning portfolio.



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 a diagnosis and treatment plan.

Pateint came to Casuality on 24th of March with 
-c/o itching & scaling of skin all over the body and scalp since 3 months.

-H/o itchy skin lesion over the body since 25 years

-H/0 swelling of joint while working since 3years

- No H/o fever

-H/o winter aggravation Ⓒ

HISTORY OF PRESENT IILNESS

H/O Decadron/Kenocart Combination Injection  for every 3 months for 6 to 7 years 
H/O Secondary Infection over injection Site since 5 months 

No Family History 
H/O Medication visited various dermatologists 
Methotrexate and plant medication 
Profisalic ointment
Betamethasone
H/O weight loss 1 month back
H/O pedal edema since 3 months

HISTORY OF PAST ILLNESS
No other Comordities

PERSONAL HISTORY
Married

Appetite- normal

Non vegetarian

Bowels- regular

Micturition- normal

Known allergies- absent

Alcohol history- Alcoholic since 10 years

Tobacco and bettelnut usage- Yes

Family history
No case of diabetes, heart diseases, hypertension,stroke,cancer, tuberculosis and asthma

GENERAL EXAMINATION 

Pt is Conscious, Coherent and Cooperative 
Thin built and Malnourished 

Pt is Pallor 
No icterus 
No clubbing 
No cyanosis
No lymphedenopathy
Pedal edema is seen 
Skin - Generalised Scaling all over the body and scalp >90% BSA 
Pavithran's Nose Sign + 

Systemic Observation- 

CVS :

No murmur 
No thrills 
S1 and S2 heart sounds heard
Rhythm - normal 
Volume - normal 

CNS:

- patient is conscious
- speech is present
- reflexes are normal
 
Respiratory :BAE+ , NCBS heard 

Per abdomen : soft , not tender

VITALS 
BP : 100/80 mm of hg 
PR : 107 bpm
RR: 18 bpm
Temp : Afebrile 

INVESTIGATIONS 
RBS - WNL
Creatinine - 0.4mg/dl
Albumin - 2.4mg/dl
Total protein - 6.1mg/dl 
Hbs Ag - Non reactive
HIV - Non reactive 

PROVISIONAL DIAGNOSIS 
ERYTHRODERMIC PSORIASIS 

CLINICAL IMAGES 




PLAN OF TREATMENT 

1.Liquid paraffin + Glycerine Water - Apply in equal proportion For 2 weeks 
2.TAB. ATARAX 25 mg  O/D For 2 weeks 
3.TAB. SHEICAL 500 mg O/D For 2 weeks 
4. ProteinXPowder 3tbsp with Glass of milk for 2 weeks 
5.High Protein Deit 
6.Multivitamin Tablets 




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