Medicine short case - 45 year old female with abdominal distension and facial puffiness

June 09, 2022

This is 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 patients 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 comment box is welcome .

I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan.

Reg no : 1701006054

CASE;

45 year old female complaints of abdominal distension and facial puffiness

Chieftain complaints

Patient complaints of

Abdominal distension since 1year

Facial puffiness since 1year

Weight gain since 1year

Itching and rash since 1year

Shortness of breath since 1week

History of presenting illness

Patient was apparently asymptomatic 1year back then she developed abdominal distension which was insidious in onset and gradually progressive

It was associated with itching and rash which started near elbow joint and gradually progressed all over the body since 1year

complaints of facial puffiness, pedal edema and SOB since 1week

Patient also had a episode of vomiting

Past history

Patient has a history of bilateral knee pain since 3 years which was insidious in onset gradual in progression pricking type of pain more in the night aggregate on walking relieves on lying down

She also has a history of itch and rash since 1 year which was diagnosed as tinea and is on medication since then

Not a known case of diabetes/ hypertension/ tuberculosis/ asthma/ epilepsy