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
X ray
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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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