General medicine final examination -practical( long case)
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CH.DIVYA
HALL TICKET NUMBER- 1701006030
A 40/F Came with chief complaints of ,
Abdominal Distension since 1 year
Associated with abdominal discomfort-diffuse abdominal pain, aggravated after eating, relieved on sleeping , sitting and after defecation.
Dizziness and headache -9 days back
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 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
Umbilicus - inverted umbilicus.
RESPIRATORY SYSTEM EXAMINATION :-
Inspection-
Ultrasound report :
2D echo :
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