65 year old man with ulcers all over the body,pedal edema,shortness of breath

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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.

AFEEFA FARZANA ,8th SEMESTER

Roll no:09

This is a case of 65 year old male patient resident of Warangal carpenter by occupation 

CHIEF COMPLAINTS 

ulcers all over the body since 2 months

Pedal edema since 10 days

shortness of breath since 10 days

Decreased urine output since 10 days 

HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 2 months ago,then he had pustules over the right hypochondriac region which eventually progressed to ulcer and relieved after using medication 

These ulcers started over his Abdomen and then he had ulcers all over his body.

He also complained of pain ,itching over the site of lesions

He had bilateral pedal edema since 10 days which progressed till knees

He had shortness of breath which is grade 3 since 10 days

DAILY ROUTINE

He had fall 13 years back for which he was operated and rods were placed in left femur. Since then he stopped working and was bedridden at home.He used to walk with the help of stand

He wakes up at 8 AM eats breakfast at 12pm and sleeps for sometime watches television and eats dinner at 8 pm

PAST HISTORY 

Not a known case of DM, HTN,epilepsy,TB

PERSONAL HISTORY 

Diet: mixed 

Appetite :normal

Sleep :adequate 

Bowel movements: regular 

Bladder movements:decreased urine output since 10 days

Addictions:  consumes gutka,he used to smoke beedi but stopped 13 years ago

SURGICAL HISTORY 

He was operated and rods are placed in left femur

FAMILY HISTORY 

No significant family history 

GENERAL EXAMINATION 

Patient is conscious, coherent, uncooperative and well oriented to time, place and person

Moderately built and moderately nourished

VITALS

BP  - 

Pulse rate - 

Respiratory rate - 17 cycles per minute 

Temp :afebrile

Pallor - present

Icterus - absent

Cyanosis - absent

Clubbing - absent

Lymphadenopathy - absent

Oedema - bilatera pedal edema till knees

SYSTEMIC EXAMINATION 

abdominal examination:- 

Abdomen is soft and non tender

No organomegaly

No shifting dullness

No fluid thrill

 

2)Respiratory examination :- 

- Chest bilaterally symmetrical, all quadrants

moves equally with respiration.

- Trachea central, chest expansion normal.

- Resonant.

- Bilateral equal air entry, no added sounds heard.

3)CVS examination:- 

- No precordial bulge.

- Apical impulse felt

- S1 S2 heard No murmus

4)CNS examination :- 

No focal neurological defects.

- all cranial neves are intact. 

LAB INVESTIGATIONS

On 12 July 2022

On 13 July 2022

Provisional diagnosis:- 

? Pyoderma gangrenosum

? Necrotising fascitis

?erythroderma under evaluation 

AKI on CKD