A 37 year old male with itchy lesions

 Medical case discussion 

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        CASE DISCUSSION

A 37 year old male came to medicine OPD with chief complaints of 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  ,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 lasted for one day relived 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 appendectomy 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  are heard no murmurs

 Per Abdomen :- soft ,non tender 

Shape of the abdomen -flat

Umbilicus -central

Bowels sounds are heard

Respiratory system 

Shape of the chest -elliptical

Trachea-central

 bilateral air entry present 

NVBS are heard

CNS :

Higher mental functions:normal

Memory intact

Cranial nerves:normal

Sensory examination:normal sensations felt in all dermatomes

Motor examination:normal tone in both upper and lower limb

Normal power in both upper and lower limb

Reflexes:

Normal,brisk reflexes elicited-biceps,triceps,knee,ankle

Cerebellar function:normal 

No meningeal signs were elicited

Provisional diagnosis:-

Systemic lupus erythematous,viral pyrexia 

Investigations:- 

 x - ray :-

Final diagnosis:-

Systemic lupus erythematous,viral pyrexia with bicytopenia(thrombocytopenia,leukopenia)

Treatment:- 

SUCROSE AQUA-GEL SPF 50 L/A

MUCO PAIN GEL L/A TID

T.PCM 650 MG PO TID

T.BENFOMET PLUS PO OD