GENERAL MEDICINE FINAL PRACTICAL LONG CASE

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HALL TICKET NUMBER- 1701006073


A 40/F Came 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

Dizziness and headache since 9 days 

H/O PRESENT ILLNESS:

Patient was apparently asymptomatic 3 years ago ,then she developed bilateral knee pain which was insidious onset and gradually progressive ,pricking and non radiating type and more at night for which she was given demisone 0.5mg and acelogic SR .

      Then she developed abdominal distension ,facial puffiness and itching all over the body since 1 year ,and associated with abdominal discomfort and diffuse abdominal pain ,aggravated after eating and relieved on sleeping ,sitting and after defecation .

       She developed SOB grade III , pedal edema -pitting type , dizziness and headache since 9days .

       She had an episode of vomiting since 2days ,which was non projectile ,non bilious , contained food particles ,and was relieved on medication .

No H/O trauma 

No H/O fever .


PAST HISTORY 

She is Denovo Diabetic 

Not a K/C/O hypertension ,asthma , ischemic heart disease ,TB 

 Past Medical history -

She is under medication( demisone 0.5 mg and acelogic SR) since 3years for bilateral knee pain and  also under medication for tinea corporis infection.


FAMILY HISTORY 

NO SIGNIFICANT FAMILY HISTORY

PERSONAL HISTORY:

DIET :Mixed 

APPETITE- decreased 

SLEEP -adequate

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.

No pallor ,icterus ,cyanosis ,clubbing and lymphadenopathy ,edema 

VITALS :

BP 110/80

PR 90bpm

TEMP 98.5degrees F

SPO2 98 @ RA

GRBS 106


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 adventitious sounds heard.


INVESTIGATIONS: 

Blood sugar random

Renal function test

Complete blood picture
Lipid profile 
Colour doppler
ULTRASONOGRAPHY 


X ray



ELECTROCARDIOGRAPHY 








PROVISIONAL DIAGNOSIS: steroid-induced cushings ( iatrogenic )  with Tinea corporis (Fungal infection ) .


Treatment plan :

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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