FINAL PRACTICAL SHORT CASE

 


Kausalya Varma, MBBS 9th semester

Roll no: 59

This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

 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 diagnosis and treatment plan. 


40 YEAR OLD FEMALE WITH COMPLAINTS OF ABDOMINAL DISTENSION AND FACIAL PUFFINESS FOR PAST 1 YEAR 


CHIEF COMPLAINTS:


40/F Came with 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 


- Shortness of breath since 5 days


- Pedal edema since 5 days of pitting type



HISTORY OF PRESENTING ILLNESS:


Patient was apparently asymptomatic 1 year back then she developed abdominal distension, facial puffiness,itching all over the body and 5 days ago she developed pedal edema and SOB grade 3.

She had an episode of vomiting two days back which contained food particles. It was relieved on medication. 



PAST HISTORY:

- She developed  B/L Knee pain - since 3years, onset - insidious, gradually progressing, type- pricking, more at the night, aggravated on walking, relieved on sitting n sleeping, no radiation and is under medication (demisone 0.5 mg and acelogic SR) 

- She developed abdominal distension and facial puffiness one year back.


- She also developed itching and skin lesions and was diagnosed as tinea and was given medications. 



Not a K/C/O DM/HTN/ asthma / Ischemic heart disease / epilepsy / TB



FAMILY HISTORY:

No significant family history is noted in this patient 


PERSONAL HISTORY:


OCCUPATION- Daily wage worker , stopped going to work since 3 months


DIET- Mixed 


APPETITE- Decreased 


SLEEP- Normal


BOWEL AND BLADDER HABITS- Dcreased urine output 


ADDICTIONS- No



GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative, well oriented to time place and person


VITALS 

BP 110/80


PR 90bpm


TEMP 98.5degrees F


SPO2 98 @ RA


GRBS 106




No pallor, icterus, cyanosis, clubbing or lymphadenopathy 


SYSTEMIC EXAMINATION:



CARDIOVASCULAR SYSTEM

Inspection :

Apex beat 5th intercostal space 



Palpation 

Apical impulse - medial to mid clavicular line at 5th ics 


Auscultation 

Mitral area

Aortic area

Pulmonary area

S1 S2+ heard , no murmurs, or any added sounds 



PER ABDOMEN 

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



RESPIRATORY SYSTEM 


BAE + , normal vesicular breath sounds










INVESTIGATIONS:


1) RANDOM BLOOD SUGARS 




2) RENAL FUNCTION TESTS



3) LIVER FUNCTION TESTS 




4) COMPLETE BLOOD PICTURE 




5) LIPID PROFILE 




6) ULTRASOUND 



7) ECG




8) X-RAY







PROVISIONAL DIAGNOSIS:


CUSHINGS SYNDROME




TREATMENT:



4-06-2022

Inj. Pantop

Inj lasix

Inj optineuron 

Tab. Ultracet

Tab.aldactone

Tab. Atarax

Tab . Zofer

Luliconazole

Syp aristozyme



5-06-2022

Ultracet

Luliconazole ointment

Rantac

Syp aristozyme 



6-06-2022

Spironolactone 

Ultracet

Luliconazole ointment

Rantac

T defloz 6mg

Syp. Aristozyme 


7-06-2022

Tab.Deflazacort

Ultracet

Luliconazole ointment

Rantac

Syp. Aristozyme




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