A 66 YEAR OLD MALE WITH MULTIPLE PAINFUL BLISTERS

My patient is a 66year old male, shepherd by occupation referred from dermatology dept.
Patient c/o blisters all over the body and a swelling of the distal part of left middle finger.
H/O itching all over the body since 5 years.

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 5years back,then he developed itching all over the body which was on and off.Five days back, patient developed multiple polysized, painful blisters on both legs&hands,buttock and on the chest,associated with crusting,oozing and bleeding.There is a swelling at the distal phalanx of the left middle finger which is associated with a blister,the swelling is filled with serosanguinous fluid and is resolved after incision and drainage.

PAST HISTORY

No h/o similar blisters in the past.
Patient is a k/c/o diabetes and hypertension since 5 years.
No h/o asthma,epilepsy,TB,CAD.

DRUG HISTORY

Telmisartan for hypertension
Metformin 500mg for DM

PERSONAL HISTORY

Diet- mixed

Appetite- normal

Sleep- adequate 

Bowel and bladder- regular

Addictions- alcohol occasionally 

Allergy -allergic to brinjal and potato.


GENERAL EXAMINATION- 

Patient is conscious, coherent and cooperative 

Moderately built and nourished 

Pallor - absent 

Icterus- absent 

Cyanosis- absent 

Clubbing- absent 

Lymphadenopathy- absent 

Edema- absent 

VITALS - 

Temperature- afebrile 

Pulse rate - 76 bpm

Respiratory rate - 18 cpm

BP - 120/80 mm of hg


SYSTEMIC EXAMINATION- 

1.Cardiovascular system

S1 ,S2 heard

No murmurs.


2.Respiratory system

Position of trachea-Central

Breath sounds-vesicular

Bilateral air entry is present 

Multiple blisters are present over the chest and back,which are associated with bleeding and crusting.


3.ABDOMEN

Soft,palpable and non tender

No organomegaly


4.CNS

Patient is conscious

Speech normal

No signs of meningeal irritating

Motor and sensory system- Normal

Reflexes - present

Cranial nerves - intact.


PROVISIONAL DIAGNOSIS

?Bullous pemphigoid

INVESTIGATIONS

-Culture and sensitivity of the pustule
TREATMENT

CAP.AMOXICLAV 625mg B/D

FUSIDIC CREAM B/D

TAB.ATARAX 10mg O/D

TAB.DOLO 650mg B/D 3 DAYS

INJ HAI SC/TID premeal
 
Strict diabetic diet 

GRBS monitoring

D/D

Bullous impetigo
Folliculitis with acute paronychia
Eczema associated with 2° bacterial infection.




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