KURSK STATE MEDICAL UNIVERSITY

DEPARTMENT OF DERMATOLOGY

CASE HISTORY MODEL

Diagnosis:PSORIASIS, Infiltrative form,

Wintage type, Progressive stage

KURSK 2015

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Identification:

Name:
Age: 72 years old
Sex: male
Nationality: Russian
Occupation:mechanical worker
Accommodation: Kosuhina,kursk
Date of admission: 25th april 2015
Date of discharge: -nil

Complaints Prior to Admission:

1. Ichiness
2. headache
3. Felt pain in joints
4. weakness
Anamnesis Morbi:
 Patient has been ill for 2years .he is having cassic well marginated
leisons.Erythamatous plaques with silvery white surfase scale.specialy
in the areas of extenser surfases uch as knees,elbows,buttoks.more
over he is suffering from diabtes mellitus.

Anamnesis Vitae:
 Patient has normal childhood. No notable past diseases has been
mentioned
 No cases of tuberculosis and allergic reaction noted
 Patient has not undergone blood transfusion
 Patient has never undergone surgery

Examination:
 Primary diagnosis: chronic recurrent psoriasis
 Receive maitain cutaneous hydration therapy
 Hospitalization before the commision

Life History
1. Childhood and youth: He was born in Kursk in a normal family
condition and normal financial circumstances.
2. Occupation: Electrician

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3. Hazards: Normal body position, normal temperature and no industrial
intoxication.
4. Financial status: are normal.
5. Living conditions: are normal.
6. Clothes: he is dressed according to the season.
7. Meals: he is taking food 4 times per day, sufficient and no specific
kind of food.
8. Body hygiene: is normal.
9. Marital status: He is not married
10. Family history: Parents are both normal
11. Past illness: no.
12. Habits: he does not smoke or drink alcohol
13. Allergy: no allergy for any kind of food or drugs.

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OBJECTIVE EXAMINATION

GENERAL INSPECTION

1. General condition
– Satisfactory condition
2. Show
– The patient appears according to the age
3. Consciousness and stage
– The patient is alert and able to answer questions
– The patient has clear mind and consciousness with GCS is 15/15.
4. Posture
- Active posture
5. Look at the face
– Normal state of face
– No edema
– No cyanosis or any other kind of discoloration
6. Weight, height, constitution, nutritional state
– Weight: 70kg
– Height: 177cm
– Constitution: Normostenic
– Nutritional state: Satisfactory
– State of development: Nourished, symmetrical
7. Skin – he is having cassic well marginated leisons.Erythamatous plaques
with silvery white surfase scale.specialy in the areas of extenser surfases
uch as knees,elbows,buttoks
Nails – pitting and thickning ,onycholysis
Hair – normal, no brittleness
8. Subcutaneous fat
– Normal development of subcutaneous fat
– Subcutaneous fat best developed around the waist region
Edema
– No traces of edema at all
9. Musculation
- Degree of development: Good
- Muscular tension: Normal
- No painfulness when palpated
- No convulsions
- Muscular strength: Normal and symmetrical

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10. Lymphatic system
– No palpable nodes
– Not painful during palpation
11. Bones
– No pathological changes
– Not painful during palpation
12. Joints .. pain and crakling sound around joints
13.Head - Size and form confirm to body
Nose - Normal
Eyes – Normal, no discoloration, normal vision, pupil’s reaction to light
is normal
Lips - Normal, no herpes, no discoloration
14. Neck
– No pathological changes
– No enlargement of thyroid gland.
– Thyroid gland is not palpable
15. Body temperature
– Fever 1st degree

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 RESPIRATORY SYSTEM

1. General inspection: Normal form of the chest, symmetrical, no

deformation, symmetrical eguality of expansion. Normal intercostals
region.
2. Type of respiration: Abdominal respiration.
Respiration per minute is 22.
Normal rhythm.
3. Palpation of the chest: During surface palpation of the chest no
pain , no deformities in ribs, in breast-bone, normal intercostals
spaces, normal vocal fremitus.
4. Percussion: Same resonant sound in comparative percussion.
5. Topographic percussion: Anteriorly the apex of each lung rises
about 3 cm above the inner third of the clavicle, the lower border of
the lung crosses the sixth rib at the midclavicular line and the eighth
rib at the midaxillary line. Posteriorly, the lower border of the lung
lies at about the level of the T10 spinous process. On inspiration. It
descends farther.
6. Auscultation: Presence of vesicular sound in which the duration of
inspiratory sounds last longer than the expiratory ones, intensity of
expiratory sound is soft, the pitch of expiratory is relatively low, the
sound is heard over most of both lungs, through the inspiration,
continue without pause through expiration, and then fade away about
one third of the way through expiration.
7. Rales: No presence of pulmonary rales.

CARDIOVASCULAR SYSTEM

1. Inspection:
 Region of the heart: No presence of cardiac humpback. No
abnormal pulsations in aorta or in pulmonary trunk.
 Region of the neck: No aortic arch or carotid arteries
pulsations, no engorgement of jugular veins, and no undulation
of neck veins.
 Peripheral arteries pulsations are absent, no worm sign.
 Epigastric pulsations are absent, no hepatic and no right
ventricle and no abdominal aorta pulsations.
 No varicose phlebectasia of lower extremities.
2. Palpation:

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  Apex beat is situated in the midclavicular line
 Aorta arch palpation is normal.
 Epigastric palpation is normal.
 Peripheral arteries palpation is normal.
 Radial artery pulsation is normal, rhythmic, no changing of
pulse during exertion.
3. Percussion:
Normal border of heart
4. Auscultation:
 Aortic regurgitation and mitral regurgitation in 4th stage and
tricuspid regurgitation
 Systolic organic murmur
 Above aorta diastolic murmur
 Some systolic murmur in tricuspid valves

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 GASTROINTESTINAL SYSTEM

EXAMINATION OF ABDOMEN

1. Size, configuration:- Symmetrical, no diverticula. No obesity.

Abdomen participates in breathing. No visible gastro-intestinal
peristalsis, no venous medusa. Absent pigmentation, striae or scars.
2. Surface palpation:- No muscle tension. No heart defects are
palpated. No palpable swelling. No hemorrhoids or any lesions
observed.
3. Liver and gall bladder:- No tenderness or enlargement. No
displacement. Palpable swellings are not observed in liver. The
borders of liver are soft and surface is smooth.
4. Spleen:- No enlargement or displacement.

EXAMINATION OF URINARY SYSTEM

– Skin redness, swelling or edema are absent in lumbar region.

– No painful points are observed in the right lumbar region.
– No displacement of kidneys.
– No kidney enlargement or pain present. Its surface is smooth and soft
consistency. No tenderness present during palpation.
– No noticeable variations are observed in examination of genital
organs.

EXAMINATION OF NERVOUS SYSTEM

– Patient’s vision is satisfactory. No abnormalities in orbital movements.

Both pupils are reactive to light at same degree. patient’s hearing is
satisfactory.
– No abnormal twitching movements are observed. Knee reflex, triceps
reflex, biceps reflex, ankle reflex and planter reflexes are positive. No
areas of anaesthesia or paraesthesia in body.

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THE PLAN OF EXAMINATION

Laboratory investigation
– Blood analysis
– Urine analysis
– Blood glucose level
– Arterial blood gases
– Bio chemical analysis of blood

Instrumental investigation
- potassium hydroxide preparation test
- tznack preparation test
- skin biopsy
- diascopy
- woods light examination
- patch test

CLINICAL DIAGNOSIS
Chronic recurrent psoriasis, Infiltrative form, Wintage type, Progressive
stage

TREATMENT
-maintain cutenous hydration
-topical glucocorticoid therapy
-topical vitamin D therapy
- etanacript apply for arthritis
- cyclosporine therapy