65 year old with multiple ulcers over body
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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT
Chief complaints:
65 Yr old male came to opd with Chief complaints of itching followed by blebs formation and spontaneous rupture, ulcers present on both the hands
HISTORY OF PRESENTING ILLNESS:
Pt. Was apparently asymptomatic 2 months back then he developed itching all over the body since 2 months. History of painful ulcers over the rt side of Abdomen which healed on taking medication. History of shortness of breath since 1 month.
History of loss of appetite since, reduced urine output and pedal oedema since 10 days.
No history of fever
Past history:
No history of HTN and DM ,Tb, asthma, thyroid abnormality. Pt sustained injury due to RTA for which both knees were operated and fixed with plating and nailing. 5 years back patient had spontaneous expulsion of those nails for which he was treated conservatively.
Personal history:
Diet: mixed
Appetite: loss of appetite since 10 days
Sleep: adequate
Bladder and bowel movement:regular
History of taking alcohol occasionally.
General examination:
Pt is conscious, coherent, cooperative well orientated with time,place ,person
Moderately built and moderately nourished
Pallor: present
Cyanosis: absent
Clubbing: absent
Lymphadenopathy:absent
Edema of feet is present.
VITALS:
TEMP: Afebrile
RR:18cpm
BP:110/80
PR:82bpm
Spo2: 98
SYSTEMIC EXAMINATION:
CVS:S1 and S2 sounds heard
RS:NVBS +, trachea : Central
CNS:no focal neurological deficit
Abdomen:
Inspection: no engorged veins, dry skin, healed ulcers
On Palpation:no tenderness seen
On Auscultation:bowel movements heard
Investigations:
Hemogram-
Serum uric acid- 8.8 mg% ( 3.5 to 7.2 mg%)
Serum Creatinine- 8.8 mg/dl ( 0.8 to 1.3 mg/dl )
Serum electrolytes -
Sodium: 124 meq/l (135 to 145 meq/l)
Potassium: 4.6 meq/l ( 3.5 to 5.1 meq/l)
Chloride: 91 meq/l ( 98 to 107 meq/l)
Serum calcium: 7 mg/ dl ( 8.6 to 10.2 mg/ dl)
LFT-
Blood urea- 243 mg/ dl ( 17 to 50 mg/dl)
CUE:
ESR : 85 mm / 1st hour ( 3 to 15)
Reticulocyte count: 0.3%( 0.5 to 2.5 )
ABG:
Ultrasound:
Impression-- b/l grade 3 RPD with sub centimetric renal cortical cysts.
Provisional diagnosis::
Pyoderma gangreosum, AKI ON CKD,
Anemia secondary to renal failure
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