A case presentation on generalised itching with breathlessness

2. Welcome to our weekly online
case presentation session
16th December 2020
Organized by
Department of Internal Medicine
Chairperson: Prof. Dr. Faruk Ahammad

4. Topic: A 70 years old man presented
with generalized itching with
breathlessness
Speaker: Dr. Md. Suzon Islam (Intern Doctor,
Colonel Malek Medical College, Manikganj)
Mentor: Dr. Dilip Kumar Sarkar (Assistant
professor, Internal Medicine)

5.  Name: Md. Abdul Khalek
 Age: 70 years
 Gender: Male
 Religion: Muslim
 Marital status: Married
 Occupation: Shopkeeper
 Address: Dokkhin Noadingi, Manikganj
 Date of admission: 17th November 2020
 Date of examination: 20th November 2020
Particulars of the patient

6. Chief Complaints
Generalized itching with multiple erythematous
scaly lesions on different parts of the body for 4
years
 Breathlessness with cough & sputum production
for 12 days
Right sided chest pain for 12 days

7. History of present illness
 According to the statement of the patient, he was reasonably
well 4 years back. Then, he developed multiple
erythematous scaly lesions in different sites of the body. It
appeared first on the extensor surface of both legs & knee
joints. Then it extended to the dorsal surface of foot & both
hands, face & back. The lesions were multiple in number and
variable in size and shape. Initially it was reddish in color
with scales. The scales were dry, thick & silvery white. The
lesions were well demarcated. There was no oozing or
discharge from the lesions. These lesions were itchy and
upon scratching there were punctate bleeding from the
lesions.

8. History of present illness (cont.)
 He was treated with some topical steroid and antihistamines
from nearby health complex and it was cured. But the
lesions recurred again after some days. He had several
attacks over the last four years. The lesions are gradually
increasing. This time it was so severe that it made the
patient to get admitted in this hospital.
 These lesions were not associated with exposure to any
allergen or food or exposure to sunlight. There is no history
of joint pain, photosensitivity & any unusual discharge. He
denies any extramarital exposure.

9. History of present illness (cont.)
 Patient also complains of difficulty in breathing for 11 years
for which he takes some medication. This is associated
with frequent cough with expectoration of mucoid sputum
which is present throughout the day and night, but more
marked upon waking in the morning. It is aggravated on
exposure to dust or smoke & more marked during
moderate to severe exertion. It is progressively increasing
day by day. Patient does not give any symptom free
interval but the symptoms were moderately controlled by
taking medication.

10. History of present illness (cont.)
 For the last 12 days patient complains of shortness of breathing. This
is present throughout the day. It was associated with cough with
productive sputum for same duration. Sputum was moderate in
amount, yellow in color, not foul smelling, not blood stained.
 Patient also complains of right sided chest pain which is sharp &
more marked during deep inspiration, coughing or exertion. There is
no radiation of pain, not associated with taking food.
 For the same duration patient complaints of occasional low grade
fever. Patient did not have any temperature record. It is not
associated with chills and rigor. It was relieved by taking
Paracetamol.

11. History of present illness (cont.)
 Patient also complains of leg swelling. It was mild. It is
relieved after taking medication. His bladder habit is
normal. He is a known case of CKD.
 There is no history of hemoptysis or any significant weight
loss over last few years. His bowel and bladder habits are
normal.
 Patient is hypertensive and non diabetic.

12. History of past illness
 Patient is known hypertensive for 3 years for which he
occasionally takes Tab. Amdocal 5mg (Amlodipine). Patient
compliance with medication was not good. Blood pressure
was not well controlled.
 Patient gives history of several attacks of generalised body
swelling over last 3 years which first appeared in face then
spread to abdomen, hands & legs. Patient also gives
previous history of cessation of micturation. Patient is a
known case of CKD for 3 years.
 Patient was diagnosed as pulmonary tuberculosis in 1988.

13. Family history
 This patient lives with his wife. He has one daughter who
is married. He had a son who died from ischemic stroke
3 years back. His son was a known hypertensive patient.
Other members of his family are in good health. Both of
his parents died from unknown disease that he can not
mention.

14. Personal habit:
 Patient is a chronic smoker. He takes around 20 cigarettes a
day. He had been smoking for 40 years. For the last few
years he is trying to stop smoking. He also have habit of
taking betel nuts & drinking tea. The Patient is non alcoholic
Socio economic history
 Patient comes from a low income family. He lives in a tin
shed, one storyed house & uses sanitary latrine and drinks
tubewell water.

15. Immunization history
Patient was not immunized under EPI schedule
Travelling history
Nothing significant
Allergy history
No significant allergic history

16. Drug history
Cap. EPL plus (Iron+Folic acid+Vit B+Vit C+Zinc)
Tab. CTZ (Cetirizine)
Tab. Famotid 20mg (Famotidine)
Cream Betavate N (Betamethasone+Neomycin)
Tab. DFX 500mg (Ciprofloxacin)
Inj. Trialon 40mg (Triamcinolone)
Tab. Monocast 10mg (Montelukast)
Tab. Doxiva 200mg (Doxophylline)
Tab. Levomin 500mg (Levofloxacin)
Tab. Fusid 40mg (Furosemide)
Tab. Amdocal 5mg (Amlodipine).
Nebulization with Windel Plus
Tab. Algin 50mg (Tiemonium)
Tab. Acifix 20mg (Rabeprazole)

17. General examination
 Appearance: Ill looking
 Bodybuild: Average
 Decubitus: On choice
 Nutritional status: Average
 Co-operation: Not well co-operative
 Anaemia: Moderate
 Jaundice: Absent
 Cyanosis: Absent
 Clubbing: Absent
 Koilonychia: Absent
 Leukonychia: Absent

18. General examination (cont.)
 JVP: Not raised
 Edema: Mild pitting edema is present in lower limbs upon
sitting & over the sacrum upon lying
 Dehydration: Absent
 Pulse: 92 bpm
 Blood pressure: 160/90 mm(Hg) in recumbent position on
single morning dose of Tab. Amdocal 5mg (Amlodipine)
 Temperature: 100 degree F
 Thyroid gland: Not palpable
 Lymph nodes: Not palpable
 Bony tenderness: Absent

19. General examination (cont.)
 Body pigmentation: Ethnic pigmentation
 Hair distribution: Sparse in itchy lesions in different sites of the
body mainly hands & legs.
 Nail examination: There was horizontal ridging, subungual
hyperkeratosis, thickening & onycholysis mainly in toe nails
also in nails of hands. Hand nails were shiny as well.
 Skin examination: There was multiple erythematous scaly
lesions of different size and shape in hands, legs, back and
face. The scales are dry, thick and silvery white. Bleeding spot
was noticed when scales were plucked out

20. Respiratory system examination
 Inspection:
Shape of the chest: Normal
Movement of the chest: Bilaterally restricted
Intercostal indrawing: Present
Using of accessory muscles for breathing: Present
 Palpation:
Trachea: Central in position
Apex beat: in the left fifth intercostal space medial to the
midclavicular line normal character
Vocal fremitus: normal
Chest expansibility: Reduced in both side.

21. Respiratory system examination (cont.)
 Percussion:
Percussion note: Resonant all over the lung field except lower part
of right lung field from 5th Intercostal space to 7th Intercostal space
where the note was woody dull.
Cardiac dullness: normal
 Auscultation:
Breath sound: Vesicular with prolonged expiration in all over the
lung field except the right lower lung field from 5th Intercostal space
to 7th Intercostal space. Here, breath sound was bronchial.
Vocal resonance: Increased in the mentioned area otherwise
normal
Added sound: Ronchi is present in both lung field.

22. Cardiovascular system examination
 Inspection: Shape of the precordium is normal.
 Palpation: Apex beat is palpable at left 5th intercostal space 9
cm from midsternal line. Normal in character.
Thrill: absent
 Auscultation: All the heart sounds are normal. There is no
murmur or added sound

23. Other systemic examination reveals no abnormality

24. Salient feature

25. Salient feature
My patient Md. Abdul khalek, 70 years old, male, Muslim, married,
shopkeeper, nondiabetic & hypertensive patient hailing from Dokkhin
Noadingi, Manikiganj was admitted in Manikganj Sadar Hospital on 17th
November, 2020 with the complaints of generalized itching with multiple
erythematous lesions with silvery white scales on different sites of the
body for 4 years, breathlessness with cough and sputum for 12 days,
right sided chest pain for 12 days.
According to the statement of the patient he was reasonably well 4 years
back. Then he developed multiple erythematous scaly lesions in
different sites of the body. It appeared first on the extensor surface of
both legs and knee joints then on the dorsal surface of both legs, hands,
face and back. Lesions were multiple in number and variable in size and
shape.

26. Salient feature (cont.)
Initially it was reddish with scales. The scales were dry, thick and
silvery white. These lesions are itchy and after scratching he noticed
bleeding from the lesion. He was treated with topical steroid and
antihistamines and it was cured but the lesions recurred again after
some days. He had such several attacks over the last four years.
Patient also complains of difficulty in breathing for 11 years for which
he takes medication. This is associated with frequent cough with
expectoration of sputum which is present throughout the day and night
but more marked upon waking in the morning. It is aggravated in
exposure to dust or smoke and more marked during moderate to
severe exertion. It is progressively increasing day by day. Patient does
not give any symptom free interval but the symptoms are moderately
controlled by taking medication.

27. Salient feature (cont.)
For the last 12 days patient complaints of shortness of breathing. This
is present throughout the day. It was associated with cough with
sputum production for same duration. Sputum was moderate in
amount, yellow in colour, not foul smelling, not bloodstained.
Patient also complains of right sided chest pain which is sharp and
more marked during deep inspiration, coughing or exertion. There is no
radiation of pain, not associated with taking food.
For the same duration patient complains of occasional low grade fever.
Patient did not have any temperature recording. It is not associated
with chills & rigor. It was relieved by taking Paracetamol.
Patient also complains of leg swelling. It was mild & it is relieved after
taking medication. He is a known case of CKD.

28. Salient feature (cont.)
There is no history of hemoptysis or any significant weight loss over
last few years. His bowel and bladder habits are normal.
Patient is hypertensive for three years and takes medication but blood
pressure was not well controlled. Patient is also a known case of CKD.
He gives history of several attacks of generalized body swelling over
last 2 years. Patient was diagnosed as pulmonary tuberculosis in
1988.
Patient is a chronic smoker. He takes around 20 cigarettes a day. He
had been smoking for 40 years. He has almost 40 pack years of
smoking history.

29. Salient feature (cont.)
On general examination patient is ill looking, average body build, not
well co-operative and moderately anemic. There is mild pitting edema
in lower limbs. Pulse is 92 b/min. Blood pressure 160/90 mm(Hg) on
morning dose of Tab. Amdocal 5mg (Amlodipine). Hair distribution is
sparsed in itchy areas of different sites of the body mainly hands and
legs. On nail examination there was horizontal ridging, subungual
hyperkeratosis, thickening & onycholysis mainly in toe nails also in
nails of hands. Hand nails were shiny as well.
On skin examination there was multiple erythematous scaly lesions Of
different size and shape in hands leg back and face. The scales are
dry thick and silvery white. bleeding spot was noticed scales were
plucked out

30. Salient feature (cont.)
On respiratory system examination we found shape of the chest was
normal. Movement of the chest was bilaterally restricted. There was
intercostal indrawing and using of accessory muscles. On palpation
chest expansibility was reduced in both side. On percussion it was
resonant all over the lung field except lower part of right lung from 5th
intercostal space to 7th intercostal space. Percussion note was woody
dull over this area. On auscultation breath sound was vesicular with
prolong expiration in all over the lung field except the lower lobe of right
lung field from 5th intercostal space to 7th intercostal space. Here
breath sound was bronchial. Vocal resonance was increased over the
mentioned area. There is ronchi present in both lung field.
On cardiovascular system examination there is no abnormality found.
On other systemic examination no significant finding was found.

31. Diagnosis ?

32. My provisional diagnosis
Psoriasis with pneumonic
consolidation with
hypertension with CKD with
moderate anemia with COPD

33. My differentials
 Chronic Eczema
 Pulmonary TB
 Bronchial Carcinoma
 Covid 19

34. Investigations

35. Hematological report on
17th Nov 2020
Hemoglobin: 8.4 gm/dl
ESR: 90 mm in 1st hour
WBC: 12,000 /cmm
RBC: 3.8 m/l
Relative Neutrophilia
Relative Lymphopenia
Relative Eosinophilia

36. CXR PA view on
17th Nov. 2020
Impression:
 Cardiomegally
 Low flat diaphragm.
hypertranslucency on both lung
field.
 Right lower lobe pneumonic
consolidation with pleural effusion

37. Biochemical report on
17th Nov. 2020
Serum creatinine: 2.29 mg/dl
RBS: 6.0 mmol/l

38. Ultrasonography
report on
17th Nov. 2020
 Mild bilateral renal
parenchymal disease
 Mildly enlarged
prostate

39. Immunological report on
18th Nov. 2020
S. IgE: 2016 IU/ml

40. Biochemical report on
24th Nov. 2020
S. Uric acid: 6.3 mg/dl

41. Hormone report on
8th Nov. 2020
TSH: 3.59 IU/ml

42. Hematological report on
7th Nov 2020
Hemoglobin: 9.5 gm/dl
ESR: 45 mm in 1st hour
WBC: 9,800 /cmm
RBC: 2.98 m/l
Relative Neutrophilia
Relative Lymphopenia
Relative Eosinophilia

43. Lab report on
7th Nov. 2020
RBS: 101 mg/dl
ALP: 82 U/l
S. Creatinine: 2.3 mg/dl
S. Electrolytes normal

44. Lab report on
26th August 2020
RT PCR for COVID 19:
Negative

45. Hematological report on
31st Oct. 2020
Hemoglobin: 8.0 gm/dl
ESR: 70 mm in 1st hour
WBC: 10,000 /cmm
RBC: 2.85 m/l
Relative Neutrophilia
Relative Lymphopenia

46. Biochemical report on
31st Oct 2020
Serum creatinine:
2.4 mg/dl

47. Biochemical report on
8th Sep. 2020
Serum creatinine:
2.29 mg/dl

48. Biochemical report on
6th July 2020
Serum creatinine:
1.6 mg/dl

49. Hematological report on
6th July 2020
Hemoglobin: 9.3gm/dl
ESR: 25 mm in 1st hour

50. Final Diagnosis
Psoriasis with pneumonia
with CKD with
hypertension with
moderate anemia with BEP
with COPD

54. Treatment

55. Treatment given on
admission
17th Nov. 2020
Tab. Xyril 25mg (Hydroxyzine)
Syp. Ambrox (Ambroxol)
Oint. Dermasol N (Clobetasol)
with Olive oil 1:1
Inj. Fusid (Furosemide)

56. After referral to consultant
of dermatology
department these drugs
were added,
Liquid paraffin
Oint. Dyven plus
Oint. Remus 0.1%

57. During Hospital stay we gradually
added and changed different drugs
according to the lab reports, clinical
examination and patient response

58. Our final
treatment plan
& treatment
given on
discharge
25th Nov. 2020

59.  Diet: Salt & protein restricted
 Tab. Xyril 25mg (Hydroxyzine)
1+1+1
 Liquid paraffin
Apply locally 3-4 times a day
 Oint. Dyvon plus (Betamethasone 0.05%+ Calcipotriol 0.005%)
Apply once daily
 Oint. Ramus 0.1% (Tacrolimus 0.1%)
Apply once daily
Treatment Plan

60. Treatment Plan (cont.)
 Cap. Cef-3 400mg (Cefixime)
1+0+1
 Syp. Ambrox (Ambroxol)
2 TSF TDS
 Tab. Amdocal 5mg (Amlodipine)
1+0+1
 Tab. Alphapress 1mg (Prazosin)
1+0+1

61.  Inj. Fusid (Furosemide)
1 amp IV stat & daily
 Tab. Dicaltrol (Calcitriol)
0+1+0
 Tab. Hypophos 667 (Calcium Acetate)
1+1+1
 Tab. Uromax 400mcg (Tamsulosin)
0+0+1
 Cap. Esoral 20mg (Esomeprazole)
1+0+1
 Tab. Disopan 0.5mg (Clonazepam)
0+0+1
Treatment Plan (cont.)