CASE OF A 46 YEAR OLD MALE WITH COMPLAINTS OF BURNING SENSATION IN THE FEET (BILATERALLY) SINCE 6 MONTHS

 CASE:-

A 46 year old male came to the OPD with complaints of burning sensation in the feet (bilaterally) since 6 months.

The pain was not associated with pedal oedema, tingling/numbness. There was no slippage of foot.

Also, it wasn't associated with tingling and numbness/ hyperpigmentation of skin

There was history of recurrent episodes of running nose, sore throat, cough (maybe due to allergic rhinitis)

There was also history of trauma to the left leg, erythematous patch was seen on the left leg which subsided by itself. History of oozing is present.

HISTORY OF PRESENT ILLNESS:-

The erythematous patch on the left leg was followed by itchy lesions of dorsum of feet bilaterally. Hyperpigmented lesion on both feet with lichenification of right foot.

HISTORY OF PAST ILLNESS:-

Not a known case of hypertension, diabetes mellitus, tuberculosis, epilepsy, CVA

TREATMENT HISTORY:-

No significant treatment history.

PERSONAL HISTORY:-

Appetite: normal

Diet: mixed

Bowels: regular

Micturition: normal

The patient has history of atopy. No habits or addictions

FAMILY HISTORY:-

No family history of diabetes, hypertension, heart disease, stroke, cancers, tuberculosis, asthma

PHYSICAL EXAMINATION:-

No pallor, icterus, cyanosis, clubbing of fingers/toes, lymphadenopathy, oedema of feet, malnutrition, dehydration

VITALS:-

Temperature: afebrile

Pulse Rate: 70bpm

Respiratory rate: 12 breaths per minute

BP: 140/100 mm of Hg

SPO2: 99%

GRBS: 109mg%

SYSTEMIC EXAMINATION:-

CVS: S1, S2 sounds heard

Respiratory system: No dyspnoea, position of trachea is central, breath sounds are vesicular.

Abdomen: shape of abdomen is obese, bowel sounds heard, genitals are normal.

CNS: The patient was conscious and alert.

DIAGNOSIS:- LICHEN SIMPLEX CHRONICUS WITH PERIPHERAL NEUROPATHY

INVESTIGATIONS:-

ECG:-

Blood Sugar Fasting:-

Serum Creatinine:-

Post Lunch Blood Sugar:-

Serum Electrolytes (Na, K, Cl):-

Blood Urea:-

Complete Urine Examination (CUE):-

Glycated Haemoglobin:-

Cross Consultation Notes and Treatment:-

Psychiatry:-

ENT:-

                                       

DVL:-

CLINICAL FINDINGS:-

46/M was brought to casualty with complaints of burning sensations in the feet (bilateral). It was not associated with pedal oedema, tingling/numbness, hyperpigmentation of the skin. There was no slippage of the foot. There was history of recurrent episodes of running nose, sore throat, cough, possibly due to allergic rhinitis. There was also history of trauma to the left leg, erythematous patch was seen on the left leg which subsided by itself. History of oozing is present. This was followed by itchy lesions of dorsum of feet (bilateral). Hyperpigmented lesion on both feet with lichenification of right foot were seen.

Personal History: Diet is mixed. Appetite is normal. Sleep is adequate. Micturition is normal. Bowel movements are regular. No habits/addictions.

Examination: Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis, lymphadenopathy, clubbing, oedema.

Vitals: Temperature: afebrile

Pulse Rate: 70bpm

Respiratory rate: 12 breaths per minute

BP: 140/100 mm of Hg

SPO2: 99%

GRBS: 109mg%

CVS: S1, S2 heard, no murmurs

Respiratory system: No dyspnoea, position of trachea is central, breath sounds are vesicular.

Abdomen: shape of abdomen is obese, bowel sounds heard, genitals are normal.

CNS: The patient was conscious and alert.

Investigations:-

   Fasting blood sugar-92mg/dl (70-110)

   Serum creatinine-1.1mg/dl (0.9-1.3)

   PLBS-117mg/dl (0-140)

   Serum electrolytes- Na: 132mEq/L (136-145), K: 4.3mEq/L (3.5-5.1), Cl: 106mEq/L (98-107)

   Blood Urea- 16mg/dl (12-42)

   CUE- normal

DIAGNOSIS:- LICHEN SIMPLEX CHRONICUS 

ALLERGIC RHINITIS 

Name of the treating faculty

Assisted by : VARSHITHA (MBBS STUDENT)

DR. NIKHILESH KRISHNA (INTERN)

DR. ABHIMANYU (INTERN)

DR. RAAGA MEGHANA (INTERN)

DR. DEEPIKA  (INTERN)

DR. BHAVYA SREE (INTERN)

DR. VAMSI KRISHNA PGY1

DR. RASHMITHA PGY2

DR. NIKITHA PGY2

DR. HAREEN (SR)

DR. ARJUN KUMAR (AP)

DR. RAKESH BISWAS (HOD)

DISCHARGE SUMMARY 

Discharge Date

Date:20/08/2021

Ward:GM WARD

Unit:V

Name of Treating Faculty DR.BHAVYA SREE(INTERN) DR.RAAGA MEGHANA(INTERN) DR.ABHIMANYU(INTERN) DR.SAI DEEPIKA(INTERN)

DR NIKHILESH KRISHNA (INTERN) DR VAMSI KRISHNA PGY1

DR RASHMITHA PGY2

DR NIKITHA PGY2

DR HAREEN (SR)

DR ARJUN KUMAR (AP)

DR RAKESH BISWAS (HOD) Diagnosis

LICHEN SIMPLEX CHRONICUS ALLERGIC RHINITIS

Case History and Clinical Findings

46Y/M CAME WITH C/O BURNING SENSATION IN THE FEET (BILATERAL) SINCE 6 MONTHS. THE PAIN WAS NOT ASSOCIATED WITH PEDAL EDEMA, TINGLING, NUMBNESS. THERE WAS NO SLIPPAGE OF FOOT. ALSO IT WASN'T ASSOCIATED WITH TINGLING, NUMBNESS, HYPERPIGMENTATION OF SKIN. THERE WAS H/O RECURRENT EPISODES OF RUNNING NOSE, SORE THROAT AND COUGH (MAYBE DUE TO ALLERGIC RHINITIS). THERE WAS ALSO H/O TRAUMA TO THE LEFT LEG, ERYTHEMATOUS PATCH WAS SEEN ON THE LEFT LEG WHICH SUBSIDED BY ITSELF. H/O OOZING IS PRESENT.

H/O PRESENT ILLNESS :

THE ERYTHEMATOUS PATCH ON THE LEFT LEG WAS FOLLOWED BY ITCHY LESIONS OF DORSUM OF FEET B/L.HYPERPIGMENTED LESIONS ON BOTH FEET WITH LICHENIFICATION OF RIGHT FOOT.

NO SIGNIFICANT PAST, PERSONAL AND FAMILY HISTORY THE PATIENT HAS H/O ATOPY

VITALS:-

TEMPERATURE - AFEBRILE

PR 70BPM

RR 12 CPM

BP 140/100 MMHG

SPO2 99% AT ROOM AIR

GRBS 109 MG/DL

SYSTEMIC EXAMINATION:

CVS S1S2 +

RS NVBS +

P/A OBESE, NON TENDER, BOWEL SOUNDS +

CNS NFND

Investigation

HBA1C 6.5%

SPUTUM FOR ZN STAIN - NO ACID FAST BACILLI SEEN

Treatment Given(Enter only Generic Name)

-DERMATOLOGY OPINION WAS TAKEN IN VIEW OF ERYTHEMATOUS PATCHES AND WAS DIAGNOSED AS LICHEN SIMPLEX CHRONICUS AND WAS ADVISED 

TAB. TECZINE 5MG OD FOR 2 WEEKS

CLOP- S CREAM L/A BD FOR 2 WEEKS

-ENT OPINION WAS TAKEN I/V/O ATOPY AND WAS ADVICED ON

SALINE NASAL DROPS TID 5 DAYS

DUONASE NASAL SPRAY 2 PUFFS BD FOR 1 MONTH

-PULMONOLOGY OPINION WAS TAKEN I/V/O SOB .

PFT WAS DONE AND WAS WITHIN LIMITS AND WAS ADVICED ON

TIOVA ROTA CAPS WITH ROTAHALER OD.

-TAB. PREGABA 75MG HS

-TAB. ZINCOVIT OD

-TAB. PAN 40MG OD

Advice at Discharge

TAB. PREGABA 75MG HS FOR 1MONTH

TAB. ZINCOVIT OD FOR 1MONTH

TAB. TECZINE 5MG OD FOR 5 DAYS

CLOP-S CREAM L/A BD

DUONASE NASAL SPRAY 2 PUFFS BD FOR 1 MONTH

TIOVA ROTA CAPS WITH ROTAHALER OD

Follow Up

REVIEW IN MEDICINE OPD SOS

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: 08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language

SIGNATURE OF PATIENT /ATTENDER SIGNATURE OF PG/INTERNEE 

SIGNATURE OF ADMINISTRATOR 

SIGNATURE OF FACULTY