63 YR OLD MALE with gouty arthritis and psoriasis

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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. 

A 63 yr old male resident of coochbehar came to opd with 

CHIEF COMPLAINTS :

Skin lesions since 2 years.

HOPI: 

The patient was apparently asymptomatic 2 yrs ago then he noticed patchy, hyperpigmented lesion on right knee joint (around Patella),which is of size(4x5cm) then after 3 months he noticed another lesion in left knee(around patella region) of size (3x4cm) , then again after 6 months he noticed similar kind of lesion on the right and left elbow joints which is of size (3x3) cm ,and a lesion at the forehead (at hairline)of size (3x3)cm ,surface and skin around the lesion is appearing normal, associated with itching he did not care about those lesions at that time as it was not associated with pain,but when his neighbours noticed and asked him repeatedly about the lesions then he consulted a physician, where he was give a ointment Tenovate , after using ointment the size of lesion got reduced to present size.

SEQUENCE OF EVENTS:

1995

In the year of 1995, when he used to stay in Assam, he noticed a swelling on the right great toe at medial side associated with pain which was insidious in onset and gradually progressive in nature, and later also noticed swelling and pain in the left great toe, alternating with right toe and on his friends advice he took a medication (tab.esgipyrin) which got him relieved in 3-4 days.

2003

In the year of 2003 when he moved to West Bengal, due to his recurring problem of swelling and pain he then consulted a orthopedician, after going through investigations,got to know about his high Uric acid levels and was diagnosed with gouty arthritis. And was prescribed with medication (tab.zyloric 100mg)  and was also advised to avoid foods like tomato,meat, seafood, soya bean and some other food which used to act as triggering factors for his high uric acid levels.

2004-2018

In this meanwhile he had no issues with the swelling and pain problem so had not taken any medicines regarding it nor visited any doctor 

2018

In the year of 2018, as swelling and pain reaccured, he started taking homeopathic medicine, later when pain was severe and he was unable to move out of the house he then consulted his family physician who advised him  to take tab.febuxostat 40mg.

2021 

He then noticed about the skin lesions of knee ,elbow and forehead  and visited a doctor where he was prescribed with ointment tenovate which caused decreased in lesions to present size.

2023

He now visited dermatologist in our hospital about the same complaint of skin lesions and was prescribed with medication and was diagnosed as Chronic plaque psoriasis was given medication of Venusia max lotion, topisal 6%lotion ,clobetacol ointment, tab.teczine 10mg 

PAST HISTORY:

He is known case of hypertension since 3 years for which he is using Tab.amlodepine. 

He is not a known case of diabetes mellitus, thyroid abnormalities,asthma, CAD,epilepsy. No history of surgeries 

DAILY ROUTINE:

He wakes up at 5-6 am in the morning and do his daily courses and goes for short walk, and at 8-9am he has his breakfast, and then he goes to the garment shop which he owns and sit there until 12pm and then he goes home for lunch and after lunch he relaxes for 1hr and take care of his garment shop until 5pm then he comes home and have tea and biscuit then later in the evening he stays in the shop and at 7pm he will come back to home for his dinner later he watches to until he falls asleep (11pm)

When he have the episodes of pain and swelling in the foot  with more severity then he used to not go to the shop and takes rest in home until it subsides.

PERSONAL HISTORY:

Patient completed his education until 12th standard and he got married in 1997and has a daughter in the year of 1998.

Diet: mixed

Appetite: normal

Sleep: adequate 

Bowel and bladder movements: regular

Addictions : Had a habit of taking alcohol occasionally which he stopped consuming on doctors advice, 

He also had habit of smoking from 1980-1995, 2-3 cigars for a day along with his friends.

Family history:

His father has type 2 diabetes mellitus 

Treatment history:

Tab.Febuxostat 40mg 

Oint.Tenovat 

Tab. Amlodipine 

General examination:

Patient was conscious,coherent,cooperative,well built and well nourished.

He had no signs of pallor,icterus,cyanosis,clubbing,lymphadenopathy,pedal edema 

Systemic examination: 

CVS: s1 s2 heard no murmurs 

Resp: BAE present NVBS heard 

CNS: No focal neurological deficits 

P/A: Soft,obese,Non tender,no organomegally 

Discharge summary:

Patient came with chief complaints of  skin lesions over forehead and itchy skin lesions over both elbows and knees and was reffered to dermatologist and on detailed examination single ill defined hyperpigmented plaque of 2*5 Cms noted over fore head and multiple scaly hyperpigemented plaque were noted over both elbows , both knees and abdomen and was diagnosed as Chronic plaque psoriasis. 

Diagnosis: Chronic plaque psoriasis with prev h/o Gouty arthritis. 

Treatment: 

Venusia max lotion BD

Topisal-6% lotion twice in a week 

Clobetacol ointment OD

Tab.Teczine 10mg OD