63M came to opd with chronic itchy skin plaques, osteoarthritis and abdominal fat

July 21, 2023

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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.

CHEIF COMPLANITS

Chronic itchy skin lesions over both axilla,hands, abdomen,groins, thighs, buttocks and osteoarthritis.

HISTORY OF PRESENTING ILLNESS

The patient was apparently asymptomatic 4months ago,then he developed chronic itchy skin lesions over both axilla,hands , abdomen,groins,thighs, buttocks and osteoarthritis.

He also has abdominal fat.

No C/O chest pain , orthopnea, PMD, decreased urine output, or facial puffiness.

PAST HISTORY

Not a known case of hypertension, DM, CVA,CAD,TB,asthama.

H/O of skin lesions on and off since 8yrs.

33yrs ago he fell from a tree and fractured his right ankle.

23yrs ago he had perforation of intestine for which he had a surgery that caused hernia and it was corrected following another surgery.

19yrs back he met with an auto accident in which he broke his left arm and left thumb for which he had a surgery.

FAMILY HISTORY

No significant family history

PERSONAL HISTORY

Cigarette and alcohol consumption for 22 yrs and then stopped it 23yrs back.

GENERAL EXAMINATION

Pallor negative

No signs of icterus,cyanosis, clubbing, lymphadenopathy and pedal edema.

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

S1 S2 heard , no cardiac murmurs.

RESPIRATORY SYSTEM

Position of trachea is central and breath sounds are vesicular.

ABDOMEN

Shape of abdomen Scaphoid, no tenderness, palpable mass, free fluid.

Bowel sounds heard

CNS

Patient is coherent, cohesive and conscious.

No neck stiffness

Reflexes are normal

SKIN

Cutaneous examination:

Multiple polysized annular scaly hyperpigmented plaques with erythematous margings noted over groin,buttocks, thigh, left waist, lower back, lower abdomen, both axilla and face. Clavus was observed on his right leg.

Above the hip on the back