40 year old female with abdominal distension and facial puffiness

 7/6/22

General medicine final practical short case

Name:M.Srilekha

 I have 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 diagnosis and treatment plan

Chief complaints:

Abdominal distension since one year 

Facial puffiness since one year

Itching all over the body since one year and developed

Multiple plaques on abdomen and lower limb.

Shortness of breath since 5 days

Pedal edema since 5 days


History of presenting illness: 

Patient was apparently asymptotic one year back then 

she developed abdominal distension, facial puffiness, 

Itching all over the body.

Five days back developed sob of grade 3

And pedal edema which was pitting type.

Past history:

She developed bilateral knee pain three years back

onset insidious,gradually progressing pricking type 

Of pain aggravated on walking and relieved on sitting

and sleeping.No radiating pain and is in medication 

(Demisone 0.5mg and acelogic SR)

One year back she developed abdominal distension and

Facial puffiness and also diagnosed with tinea and medications were given

Personal history:

Occupation : daily wage worker 

Diet mixed

Appetite decreased 

Sleep adequate 

Bowel and  bladder: decreased urine output 

No addictions 

Family history:

Not significant 

General examination:

Patient is conscious coherent and cooperative 

well oriented to time place and person 

Vitals pulse rate:90bpm

                   BP:110/70mmhg

        Respiratory rate:20cpm

             Temperature: afebrile 

             SpO2: 98%@room air

No pallor icterus cyanosis clubbing generalised lymphadenopathy  edema             

Lesions on back 

Scratch marks on legs 


              

Systemic examination:

CVS

Inspection apex beat at 5th inter coastal Space

Palpation: apical impulse medial to midclavicular line

at 5th inter coastal space

Auscultation:S1 S2 sounds heard no murmurs and 

no added sounds

Abdominal examination:

Inspection distended abdomen Umbilicus inverted 

No visible gastric peristalsis.

Palpation soft ,non tender ,no organomegaly 




Respiratory system : BLAE present 

                                  NVBS 

Investigations:









Treatment:

Inj. Pantop
Inj lasix
Inj optineuron 
Tab. Ultracet
Tab.aldactone
Tab. Atarax
Tab . Zofer
Luliconazole
Syp aristozyme



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