70 yrs male with multiple skin lesions

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 box is welcome

 

Case discussion

    

70yr Male patient came to opd with c/o lesion associated with itching all over the body since 20days.

Pt. was apparently asymptomatic 20days back then he developed intense itching over the posterior trunk then his attender noticed fluid filled lesion over the back The lesion is initially small in size and gradually increased in size. lesions rupture spontaneously or by scratching. The lesion ruptures and serous discharge is present resulting in the development of new lesion in the surrounding area.
Then spread to both upper limbs,lower limbs,trunk,face and forehead.
After 10 days he consulted local doctor and took medication( oral steroids) for 2days,following which he developed bilateral upper limb edema which is pitting type.
No h/o fever, redness.
No contact history.

Past history:

No h/o similar complaints in the past.
Not a k/c/o DM, HTN, TB, Asthma, CHD,Thyroid diseases.
No surgical history.

Personal history :

 He was a mason by occupation and stopped working since 10 years

        Diet- mixed

        Appetite - decreased

        Sleep - inadequate

        Bowel and bladder habits - regular 

        Chronic smoker since he was 10yrs old

        Occasional  alcohol consumpution(90ml)

        Stopped smoking and alcohol consumption since            1month.

Family history:

No similar complaints in the family.

General Examination:

                  Pt is conscious,coherent and cooperative.                Thin built, moderately nourished.
 

Vitals:

       Afebrile
       BP - 110/70 mm of hg
       Pulse - 84bpm
       RR - 16cpm
       Spo2 - 98% at RA
       
No signs of pallor, icterus, cyanosis, clubbing,koilonychia,lymphadenopathy

O/E

Multiple hyperpigmented plaques noted over an erythematous background with central crusting all over the limbs, trunk and face along with few fluid filled lesions over the body.

  

Oral mucosa - normal
Genital mucosa - normal
Sensation and nerves - normal
Edema - bilateral pitting type involving hands,wrist and forearm.

Systemic examination:

CVS - s1s2 heard , no murmurs

RS - BAE present, NVBS heard,no added sounds

CNS EXAMINATION

HMF normal 

All Cranial nerves intact 

Gait - normal

Motor system:

          Bulk - normal 
          Tone- normal
          Power -normal

          Reflexes-          right               left

          Biceps                +2                 +2
          Triceps               +2                 +2
          Knee                   +2                 +2
          Ankle                  +2                  +2
          Plantar          extensor        extensor

Sensory system examination : normal

Cerebellar signs - intact

Per abdomen: 

soft, non tender, no organomegaly , no palpable masses bowel sounds heard

Depending on the clinical condition of the patient the skin biopsy was planned and following investigations were done.

Day 1

Day 2

Day 3

 

Punch biopsy was done

A 4.5x4.5 mm punch biopsy specimen taken from lesion over anterior aspect of left thigh.Done under local anaesthesia.

Day 4

Day 5

 

Treatment plan was changed from doxycycline and augmentin to Tab.azithromycin as there was no improvement.

Liquid paraffin is stopped because pt complained about skin excoriation after applying it.

Day 6

        

Urine and blood culture sensitivity shows no       growth 

Pt developed lesions in the oral mucosa 

Treatment :

      

1. Tab.ATARAX 25mg OD
2. Inj.AUGMENTIN 1.2gm BD
3. Fusidic acid cream L/A BD
4. Tab.Doxy100mg BD
5. Liquid paraffin all over  the body BD x 7days

6. Tab.Azithromycin 500 mg OD

7. Syr.Cremaffin plus 15ml OD

https://drive.google.com/file/d/1edzcsdEdt5vlB8yWSnIM9f1442t0t4PL/view?usp=drivesdk