FINAL PRACTICAL EXAMINATION - LONG CASE

This is an 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 patient's 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 the comment box .

G.Sahithi Reddy

Hall ticket no - 1701006043

A 40 year old female came to OPD with 

CHIEF 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 9 days
pedal edema since 9 days pitting type
H/O OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 1 year back then she developed abdominal distension, facial puffiness,itching all over the body and 9 days ago she developed pedal edema and 
SOB grade 3.
she had an episode of vomiting two days back which was non projectile and non bilious 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

MENSTRUAL HISTORY
menarche - 13 years
Regular monthly cycles 
No of pads - 2
No clots 
Menopause - 35 years

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
VITALS 

BP 110/80

PR 90bpm

TEMP 98.5degrees F

SPO2 98 @ RA

GRBS 106

No Pallor , ICTERUS , CYANOSIS, CLUBBING , LYMPHADENOPATHY ,

SYSTEMIC EXAMINATION:

CVS-
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 

P/A-
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

RS - BAE + , normal vesicular breath sounds

Renal function tests
Random blood sugar
Liver function tests
Complete blood picture
Lipid profile
Ultrasound

ECG


X-RAY

PROVISIONAL DIAGNOSIS:

Steroid induced Cushings

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

8-06-2022
Ultracet
Rantac
Tab.Deflazacort
Syp.Aristozyme

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This is an 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 patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient-centred online learning portfolio and your valuable comments 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 a diagnosis and treatment plan.  G.Sahithi Reddy Hall ticket no - 1701006043  A 71 year old male patient came to opd with     CHIEF COMPLAINTS OF  Breathlessness and  cough since 20 days HISTORY OF PRESENTING ILLN
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