A 66 year old man came to hospital with severe itching and pustules since 3 days
General medicine
A 66 years old man came to hospital with severe itching and pustules since 3 days
August 08, 2022
Hi, I am Nithin Maridi (roll no :82)3rd sem medical student. this is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.
A 66 yr old male patient farmer by occupation with itching all over his body since 5 years.pustules since 3 days.
Chief complaints
The patient came to the hospital 8days back with chief complaints of excessive itching with blisters all over his body.
History of present illness
Patient is suffering from itching from past 5 years
and took black magic treatment for painful lesions on both legs,chest and both arms
History of past illness
In the past due to lack of micturation the patient had undergone an surgery.
The patient is also diagnosed with hypertension 2yrs back and diabetes 5 years backs.
The patient is not a known case of asthma and
tuberculosis.
Personal history
Diet:mixed
Appetite:normal
Sleep:normal
No known allergies
General examination
No pallor
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
No pedal odema
SYSTEMATIC EXAMINATION:
B. CARDIO VASCULAR SYSTEM
1. Thrills No
2. Cardiac Sounds
3. Cardiac murmurs No
C. RESPIRATORY SYSTEM
1. Dyspnoea - No
2. Wheeze - No
3. Position of Trachea - Central
4. Breath Sounds - Vesicular
5. Adventilious Sounds - No
D. ABDOMEN
1. Shape of abdomen - Scaphoid
2. Tenderness - No
3. Palpable mass - No
4. Hernial Orifices Normal
5. Free Fluid No
6. Bruits No
7. Liver - Not palpable
8. Spleen - Not palpable
9. Bowel sounds -Yes
Clinical images :
Test reports :
Probable diagnosis : bullous pemphigoid
Treatment
Dolo 650mg
Amoxiclav 625mg
Fiduc cream
Atarax 10mg
Aceclo P
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