A 45 year old female with abdominal distension

June 08, 2022

45year old female with facial puffiness

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Name : G.Rahul sai
Hall ticket: 1701006059

45 year old female came to opd 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 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

MENSTRUAL HISTORY:

Menarche -12 years

Irregular monthly cycles,Menorrhagia for 4 days

No of pads per day -2

No clots

Menopause -3years back

GENERAL EXAMINATION :

Patient is concious coherent and coperative, well oriented to time place and person.

VITALS

BP 110/80

PR 90bpm

TEMP 98.5degrees F

SPO2 98 @ RA

GRBS 106

No Pallor , ICTERUS , CYANOSIS, CLUBBING , LYMPHADENOPATHY

Height; 155cm

Weight : before 1 year: 57kg

Now: 78kg

BMI: before 1 year: 23.75kg/sqm

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

P/A-

Inspection:

Abdomen is distended

Umbilicus is inverted

Movements :- gentle rise in abdominal wall in inspiration and fall during expiration.

No visible gastric peristalsis

palpation : SOFT, NON TENDER, NO ORGANOMEGALY

RS - BAE + , normal vesicular breath sounds