A 70 year old male with Uncontrolled diabetes with cervical spondylosis ¿ and tinea corporis

14/12/22

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 patient's clinical problems with collective current best evidence based inputs. 


This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment.

Sanidha Singh
206




A 70 year old male farmer by occupation and resident of Motkur came to the medicine OPD with complaints of neck pain and itching, increased frequency of urination and increased thirst.


CHIEF COMPLAINTS:
White spots all over the body since 1 and half year (referred to DVL)
Neck pain and itching around the neck since 1 year (referred to Orthopaedics)
Increased frequency of urination since 20 days 
Increased thirst since 20 days 
Burning sensation in his feet since 20 days
Watering of the eyes



HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 1 and half year back then he  noticed white spots all over his body which was associated with itching. He went to a nearby clinic and was prescribed an ointment (Clotrimazole cream 1%).

Patient developed neck pain 1 year ago which was radiating to the left upper limb  associated with itching, giddiness, tingling and numbness which is aggravated by work and relieved on medication. Not associated with tinnitus, nausea and vomiting. Patient was experiencing pain while lifting the left upper limb. No h/o trauma. He was also experiencing burning sensation, tingling and numbness in his feet since 20 days.

Patient also complaints of increased frequency of urination especially during night and increased thirst , weakness and fatigue since 20 days which was associated with dryness of mouth and increased appetite. He then went to the local doctor and got his GRBS checked (which was around 400) and was started on medication (not known to the patient). Not associated with facial puffiness or oedema, burning micturition.









PAST HISTORY: 
20 years back patient underwent gastric surgery ( done in Nalgonda)
6 years back polypectomy
K/C/O Diabetes mellitus since 10 years
N/K/C/O Hypertension, asthma, CAD, TB, epilepsy.



FAMILY HISTORY: 
No significant family history.



DRUG HISTORY:
Prescribed by a doctor in Nalgonda for his itchy scaly lesion. 




PERSONAL HISTORY:

Diet- Mixed 

Appetite- Increased

Sleep- Inadequate 

Bowel & bladder- Nocturia (20 times)


GENERAL EXAMINATION: 

Pallor-present

Icterus-absent

Clubbing-absent

Cyanosis-absent

Oedema- absent

Lymphadenopathy-absent








VITALS:

Temp- 98.5

Pulse- 96 bpm

RR- 18 cpm

BP- 130/80 mmHg

Spo2- 98%






SYSTEMIC EXAMINATION: 

Per Abdomen :  Bowel sounds present, Normal shape, No tenderness, No palpable masses

CVS : S1 & S2 Heard , No murmurs 

RS : Central position of trachea, Vesicular breath sounds, No wheeze, no dyspnea

CNS : NAD


INVESTIGATIONS:

                                                                         On 9/12/22:









On 12/12/22:


On 13/12/22:



ORTHOPAEDIC REFERRAL: 
On examinations of cervical region: 
Skin: Normal
Swelling: Absent 
Tenderness: Present over the cervical C3-C5, C6, C7 region
ROM: Flexion and extension painful 
Distal pulses: Present 
Sensation: Intact 
Abnormal defect: Absent 
No motor and sensory deficit 



DVL REFERRAL: 
On examination: 
Multiple hyper-pigmented poly sized plaques with scaling noted over B/L groins, neck, face, few scales noted over the the scalp.
Diagnosis: TINEA CORPORIS 



PROVISIONAL DIAGNOSIS:
Uncontrolled Diabetes- II with cervical spondylosis ¿ and tinea corporis 



TREATMENT HISTORY:

1) IVF NS @ 75ml/hr
2) Tab PREGABA-M1 PO/OD
3) Tab GLIMI-M3 PO/BD
4) Tab Ultracet 1/2 tab QID 


5) Lucifin cream ODX2 weeks


6) Ebernet cream ODX2 weeks




















Comments

Popular posts from this blog

My Internship Journey in General Medicine

48F OPD patient with Diabetes Mellitus type II since 10 years and neuropathy since 15 days

40 year old male patient with type II diabetes mellitus with diabetic foot, hypertension and acute gastritis.