KURSK STATE MEDICAL UNIVERSITY DEPARTMENT OF DERMATOVENEROLOGY

Head of Department: Prof. Silina L.V. Assistant: Sirotkina E.I.

CASE HISTORY
Name of Patient: Shumakova Nina Ivanovna Diagnosis: Infiltrative Progressive Psoriasis-Winter type

Name of student: Mohd Hayat Bin Elias Group No. 7 4th Year, 2nd Sem Medical Faculty. KURSK-2008

I.

Passport Data:

Date of admission: 1st February 2008 Date of discharge: not available Name: Shumakova Nina Ivanovna Age : 55 years old Sex : Female Weight : 95kg Height : 1.70m Address: House No. 012, Apartment No. 2, Shepkina Street, Kursk. Marital status: Married Occupation : Pensioner Associated disease : Diabetes Mellitus Type 2 Complication: Blood group: AB Rhesus factor: Positive Operation: Allergic status : Blood transfusion in the past: -

II. Patients Complaints: Patient at first complaint of popular eruptions on the extensor surface of hand and scalp, at occipital area. Later, the eruptions were accompanied by itching. Scaling are presents, which can scrape off easily. Besides that patient also suffer from weakness and somnolence. III. Anamnesis of Present Illness: The disease begin with the formation of eruption at scalp. Later, it spreads to hand. Itching accompanied the eruptions. The eruptions started in 7-8 weeks ago. The popular eruptions appears at the occipital area of scalp, and also at the extensor surface of arm, back of palm also included. Diffuse shiny scales appear on scalp and hands. If the scales were scraped off, shiny scales were seen. Itchiness cause her to scratch the lesion area, and this later cause pin-point bleeding. According to the patient, it was the first time she contacted the skin disease of such severity. However, she does believe that the overcooling during the winter season does contribute to her diminished body resistance and poor health condition. IV. Anamnesis of Life: Patient does not have any known hereditary skin diseases. However during childhood, due to poor living condition, she suffered from various infectious diseases and thus contributed to her low immunity. Condition of current life is satisfactory. Patient drinks occasionally but is not smoking. She suffered from Diabetes Mellitus Type 2 for almost 15 years. Patient is not allergic to any drugs.

V. Subjective Examination: Respiratory System: Breathing through nose easily. No grasping and dryness feeling in the throat. Absent of cough, sputum, and hemoptysis and dyspnoea. Cardiovascular System: Regular heart beat, no symptom of palpitation, present pain in cardiac region. Absence of edema Digestive System: Appetite is normal. Distinguish tastes: normal No dryness in the mouth Chewing food: Normal Swallowing is normal Passage of food: normal No pain in the abdomen Flatulence is absent. No constipation, no bleeding, no pain, no anal itching No diarrhea. Urinary System: No pain in the lumbar region Lymphatic System: No enlargement of any of lymph nodes Osteomuscular System: Joints and bones are normal.. No muscles pain, no trembling, no convulsions. Nervous System: Difficulty in sleeping at night. No paresthesia, no sensation of numbness, no fever, no prickling, no blurring of colors Organs of sense: Vision: Normal Audition: Normal Smell: Normal Taste: Normal Touch: Normal

VI. Objective Examination: GENERAL INSPECTION: General condition: Satisfactory Show: Confirms to age Consciousness and Alert stages: Posture: Normal Face: No specific face Nutritional state: Good Skin and mucous Usual color of the skin and mucous membranes. membranes: Condition of scalp and hair follicles are normal. . PALPATION Skin: Normal turgor and elasticity, mild dryness in the skin Nails: Normal Hair: Normal Subcutaneous Normal, no subcutaneous emphysema, symmetrical fat: distribution of fat Lymphatic No enlargement of lymph nodes system: Muscles: Symmetrical, no pain, no weakness, no convulsions, no tremor Bones: No deformities, no clubbing of fingers Joints: Normal size, skin is normal over the joints, normal temperature, no pain during palpation Movement: Active, no difficulty in movement. Head: Normal size and form of skull, no scars, no tremor Nose: Normal form. Septum is normal and there is no deviation. Participates in respiration Eyes: Normal, no enophthalmus or exophthalmus Lids: No edema, no ptosis. Sclera: white. Conjunctiva: normal. Cornea: no scars, no ulceration. Pupils: normal. Vision: Normal.

Neck (thyroid gland):

No enlargement

RESPIRATORY SYSTEM: General inspection: Type of respiration: Surface palpation: Comparative percussion: Normal form , symmetrical, no deformation Abdominal breathing Not painful, no fractures of ribs, sternum is normal, intercostals spaces are normal, vocal fremitus: normal Normal

CARDIOVASCULAR SYSTEM Inspection: No abnormality revealed in the region of the heart: no cardiac humpback, normal apex beat. Region of the neck: Normal Trachea: Position : In the midline, no lagging Peripheral artery Normal pulsation: Epigastric pulsation: Pulsation absent Palpation: Apex beat palpated in the 5th ICS 1 cm laterally from the left margin of sternum. Aortal palpation and Normal pulmonary artery palpation: Configuration of the Normal configuration of heart heart: Auscultation: Normal heart sounds without murmurs, gallop rhythm No Duroziers double murmur or Traubes double tone Arterial pressure: 140/70 mmHg

GASTROINTESTINAL SYSTEM Inspection Oral cavity: Normal odour without acetone smell, fetor hepaticus, putrefactive or urine smell Gums: Normal pinkish color without pigmentation, ulceration and pyosis Mucous membranes: No ulcers, no pigmentation Tongue: Normal size, color, dryness clean without pathological features Tonsils: Normal size, color& texture Abdomen: Normal size, without retracted belly or frog belly. Its symmetry without diverticulus, there are no striae, pigmentation or scars. Umbilicus is normal, not intruded. Surface abdominal Not painful, no muscle tension over the region of palpation: projection of the gall bladder and no hernias Palpation of intestine: Sigmoid: Caecum: Ascending colon: Transverse colon: Descending colon: Stomach Liver: Spleen: Murphys sign Mussys sign Rebound sign URINARY ORGANS: Inspection of lumber Normal, Absence of edema, no redness region Percussion Paternatsky symptom negative on both sides. Palpation Not painful, No swellings or abnormal structures can be palpated Kidney displacement: No displacement of the kidney. Normal size and form of the kidneys Urinary bladder: Not palpable Not palpable due to subcutaneous fat Not palpable Not palpable Not palpable Not palpable Not palpable Not palpable Not palpable Negative Negative Negative

VII. The Local (Dermatologic) Status:

Papular eruptions on the extensor surface of hand and scalp, at occipital area. The papules are flat and have a rough surface covered with silver- furfuraceous or micro-lamellar scales which scrape off easily. Papules size is of the size of a pinhead or a millet. Later, the eruptions were accompanied by itching. Scaling are presents, which can be scraped off easily. The disease begin with the formation of eruption at scalp. Later, it spreads to hand. Itching accompanied the eruptions. The eruptions started in 7-8 weeks ago. The popular eruptions appears at the occipital area of scalp, and also at the extensor surface of arm, back of palm also included. Diffuse shiny scales appear on scalp and hands. If the scales were scraped off, shiny scales were seen. Continuous scratching of the lesion cause pin-point bleeding. In other words, psoriatic triad is seen. VIII. Primary Diagnosis: Psoriasis

IX. Laboratory, Instrumental Investigation And Special Methods of Investigation Common analysis: Common blood test Biochemical blood test Urine analysis Investigation of excrement on the presence of eggs, worms, RW,HIV Laboratory investigations: Microscopy- presence of Streptococci and Staphylococci in the culture taken from the purulent secretions. For differential diagnosis: Serological: Immunofluorescent Test(IFT) Immune Enzyme Analysis: PCR, ELISA X. Differential Diagnosis:
The differential diagnosis is made with psoriasiform and pustular syphilids which are characterized by more marked infiltration of the eruption, the detection of Treponema pallidum in the serum and positive serological tests. The disease must also be differentiated from lichen ruber planus, the papules in which are not rounded but polygonal, scaling is mild, and the lesions are violet-red. The absence of

the psoriatic triad and the predominant localization of the lesions on the flexor and not on the extensor surfaces of the limbs are also taken into account. A differential diagnosis has also to be made with Gibert's pityriasis rosea, sebor-rhoeic eczema, some dermatomycoses

XI. Clinical Diagnosis: Progressive Infiltrative Psoriasis of Winter-type

o According to clinical picture: Infiltrative o According to the stage of the process: Progressive stage o According to the climatic factor: Winter type o According to size of lesion: Psoriasis punctata

XII. Treatment: Systemic Therapy:

Irritating agents (psoriasinum, chrysarobin, potent keratoplastic ointments) are not applied in the progressive stage when there are fresh eruptions so as to avoid exacerbation of the process, Antihistamines and sedatives which have a soothing effect on the nervous system as well as hyposensitizing agents (intravenous infusion of calcium chloride, calcium gluconate or sodium hyposulphate solutions) and vitamins prescribed in this period (B x and B6 injections) are a beneficial measure. Suggestive therapy, sedatives, vitamins (A, G, E, B x , B 2 , B 6 , B12, B16, nicotinic and folic acids), blood transfusions, stapnylo-coccus toxoid, gamma globulin, pyrogenal and griseofulvin are indicated in the stationary and regressive stages. Persistent cases unresponsive to treatment are treated with other drugs, cytostatics (antimetabolites) such as Metatrexate and 6-mercaptopurine. These agents are prescribed with care and treatment with them is carried out under in-patient conditions; one or two tablets are given daily in courses of 5 to 7 days (with similar intervals between courses)-Treatment consists of two to four courses, depending on the therapeutic effect and tolerance. Glucocorticoids (15-20 mg of triamcinolone or 30-40 mg of prednisolone or methylprednisolone daily) as well as ACTH-zinc-phosphate (20-30 U every other day) are recommended in diffuse exudative psoriasis, erythroderma and arthropathic psoriasis. Psoriatic affection of the joints is an indication for the prescription of Buta-dione (phenylbutazone), Metobrin, Brufen (Ibuprofen), Rumalon, salicylic agents and synthetic antimalarial drugs. In prolonged medication with corticosteroid drugs it is expedient to combine them with anabolic agents of hormonal and non-hormonal action. In the complex of general treatment for psoriasis, success has been gained with pyrogenic agents (pyrogenal, prodigiosanum, 20-50 to 100-300 MPD, a total of 600-1000

MPD) and streptoantigen and staphylococcus toxoid injected intracutaneously in a dose of 0.25 to 2.0 ml every three or four days. It is best to apply antimalarial agents (chloroquine phosphate, plaquenil, nicotinic acid, chloroquine) in summer forms of psoriasis. Vegetarian diet poor in fats and rich in potassium is recommended. The restriction of fats and inclusion of vegetable oils in a complex with lipolytic agents (cetamiphenum, clofibrate, methionine, polysponinum, 0.1 g three times a day) in the diet is indicated in marked disorder of lipid metabolism. Physiotherapy is used widely as stage treatment in psoriasis. It includes ultraviolet rays (mainly in the winter form of psoriasis and not in the progressive stage), indirect diathermia and Bucky's rays. Treatment at spa and health resorts and balneal therapy (sulphurated hydrogen, radon, and natural brine baths) are indicated,photochemotherapy has recently been applied with success in psoriasis. The method is based on the combination of oral photosen sitizing agents (8-methoxypsoralen syn. Methoxsalen, beroxanum)and irradiation with ultraviolet rays of a wavelength of 320-400 nm)

External Therapy:

Non-irritating ointments (with2 per cent salicylic acid or 2 per cent sulphur, 5 per cent naphthalan,Rybakov's boric acid-solidol ointment, Unna's cream) are prescribed in the stage (progressive). Ointments or creams with corticosteroids (Locasalen, Locacorten,tar, Flucinar, ultralan, Celestoderm, etc.) are also indicated

Prognosis: The life prognosis is favourable despite the long duration of the disease and the development of recurrences.