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Hyndavi Konakanchi, 9th semester
Hall ticket number : 1701006085 - LONG CASE
June 10, 2022
A CASE DISCUSSION 40 YR OLD FEMALE WITH ABDOMINAL DISTENSION AND FACIAL PUFFINESS SINCE 1 YEAR
I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
Following is the view of my case :
A 40 yr old female patient who is a daily wage worker came to the OPD with the CHEIF COMPLAINTS of
Abdominal Distension since 1 year
Facial puffiness since 1 year
Itching all over the body since 1 year and developed multiple plaques on abdomen and Lower limbs
Sob since 5 days
pedal edema since 5 days pitting type
TIMELINE OF EVENTS
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 1 year back then she developed abdominal distension , associated with abdominal discomfort- diffuse abdominal pain — which was aggravated after eating , releived on sleeping/ taking rest , sitting & after defecation .
facial puffiness,itching all over the body &
5 days ago she developed :
pedal edema and SOB grade 3.
she had an episode of vomiting two days back which was non projectile , non bilious & it contained food particles. It was relieved on medication.
PAST HISTORY
* She developed B/L Knee pain - since 3years, onset - insidious, gradually progressing, type- pricking, non radiating , more at the night, aggravated on walking, relieved on sitting and sleeping & on medication.
No history of trauma. No history of fever swelling in the knees during the pain
* She developed abdominal distension and facial puffiness one year back
* She is diagnosed with (itching skin lesions)— tinea corporis since 1 yr amd she is put on medication for it.
MEDICAL HISTORY:
* She is under medication( demisone 0.5 mg and acelogic SR) since 3 yrs
Not a K/C/O DM/HTN/ asthma / Ischemic heart disease / epilepsy / TB
FAMILY HISTORY
No significant family history
PERSONAL HISTORY
OCCUPATION : Daily wage worker , stopped going to work since 3 months
DIET : Mixed
APPETITE : Decreased
SLEEP : Normal
BOWEL AND BLADDER HABITS : decreased urine output
ADDICTIONS: No
GENERAL EXAMINATION
* Patient is concious coherent and coperative, well oriented to time palce and person
* Built - obese , moderately nourished
VITALS
Blood pressure : 110/80
Pulse Rate : 90bpm
Temperature : 98.5degrees F
SPO2 : 98 @ RA
GRBS : 106
* NO PALLOR , ICTERUS , CYANOSIS, CLUBBING , LYMPHADENOPATHY
SYSTEMIC EXAMINATION
CVS EXAMINATION
Inspection-
* The chest wall is bilaterally symmetrical
* No raised JVP.
Palpation-
* Apical impulse is felt in the left 5th intercostal space, medial to the midclavicular line
* No parasternal heave felt.
Percussion-* no pericardial effusion
Auscultation-
## Mitral area , aortic area , pulmonary area
* S1 and S2 heard, no added thrills and murmurs are heard
PER ABDOMINAL EXAMINATION :-
Inspection:
* Abdomen is distended
* Umbilicus is inverted
Movements :
* Gentle rise in abdominal wall in inspiration and fall during expiration.
* No visible gastric peristalsis
palpation :
* SOFT, NON TENDER, NO ORGANOMEGALY
Percussion:
No fluid (ascitis)
Auscultation:
* Normal bowel sounds.
RESPIRATORY SYSTEM EXAMINATION :-
Inspection-
* Upper respiratory tract - Normal
* Shape of chest - elliptical & Bilaterally symmetrical
* Trachea- in midline
* no scars and sinuses
* no visible pulsations
* no engorged veins
* no usage of accessory respiratory muscles
Palpation-
* No local rise of temperature
* No tenderness
* All the inspectory findings are confirmed
* Apical Impulse :- 5th intercostal space 1 cm medial to mid clavicular line
* Trachea is in normal position.
* chest expansion - normal.
* Movements of chest with respiration are normal.
vocal fremitus - normal.
Ausclutation-
* Bilateral air entry - present.
* Normal vesicular breathsounds are heard.
* No advantitious sounds heard.
INVESTIGATIONS :
Blood sugar- random:
Renal function tests:
Liver function tests:
Complete urine examination:
Complete blood examination:ECG:
Ultrasound report :
X RAY:
TREATMENT :
Inj. Pantop
Inj lasix
Inj optineuron
Tab. Ultracet
Tab.aldactone
Tab. Atarax
Tab . Zofer
Luliconazole oitment
Syp aristozyme
Rantac
Spironolactone
CUSHING SYNDROME MAY BE DUE TO STEROID ABUSE ,
Query : STEROID ABUSE MAY BE FOR RHEUMATOID ARTHRITIS
DIAGNOSED AS DENOVO DIABETES, steroid induced hyperglycaemia
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