14/12/22
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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
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