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A 40yr old female with chief complaints of abdominal distension and facial puffiness since 1year

A 40 year old female with chief complaint of abdominal distension and facial puffiness since 1 year

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 .

K.ROHITH DHARMA

  Hall ticket no - 1701006074

CHIEF COMPLAINTS 

A 40yr old female came with the 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  5 days 

pedal edema since 9 days ,pitting type



HISTORY OF PRESENT 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- pitting type.

She has developed SOB of 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 has bilateral knee pain since 3 years.

Onset- insidious

Duration- 3 years

Gradually progressing

Type- pricking

Non radiating

More at the night

Aggravated on walking

Relieved on sitting ,sleeping and medication.

No history of trauma

No history of fever , swelling in the knees during the pain.

She is diagnosed with Tinea corporis infection since 1 year and she is put on medications for it.

 Medical history -

She is under medication( demisone 0.5 mg and acelogic SR) since 3years.

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


FAMILY HISTORY 

NO SIGNIFICANT FAMILY HISTORY


PERSONAL HISTORY:

OCCUPATION - worker in a glass factory

DIET -MIXED

APPETITE- decreased 

SLEEP -NORMAL

BOWEL AND BLADDER HABITS : decreased urine output 

ADDICTIONS: NO


MENSTRUAL HISTORY:

Menarche -13 years

Regular monthly cycles

No.of pads per day -2

No clots

Menopause -35 years


GENERAL EXAMINATION 

Patient is concious ,coherent and coperative

 built - obese , moderately nourished.

VITALS 

BP 110/80

PR 90bpm

TEMP 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-
S1 and S2 heard, no added thrills and murmurs are heard

PER ABDOMINAL EXAMINATION :- 

Soft and non tender .
No visible peristalsis.
Normal bowel sounds.
NO HEPATOSPLENOMEGALY elicited

Umbilicus -  inverted umbilicus.


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 DONE ON 31-5-22 :

Blood sugar- random:


Renal function tests:


Liver function tests:


Complete urine examination:


Complete blood examination.


Lipid profile-

ECG:


Ultrasound report :


2D echo :


X-ray :


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


Rantac
Syp aristozyme 

Spironolactone 
T defloz 6mg
Syp. Aristozyme 

Tab.Deflazacort


PROVISIONAL DIAGNOSIS:  

steroid-induced cushings 



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