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
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 legsSystemic 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:
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