General Medicine E-log by Shishira Reddy: A 40 year old female with chief complaint of abdominal distension and facial puffiness since 1 year

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Name : A Shishira Reddy
I would like to thank Dr. Keerthi for providing with the case details.

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

Sob since 5 days

pedal edema since 5 days pitting type

H/O PRESENT 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

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