40 YEAR OLD FEMALE WITH PERIORBITAL PUFFINESS

40 YEAR OLD FEMALE WITH PERIORBITAL PUFFINESS 

** This is an ongoing case. I am in the process of updating and editing this ELOG as and when required.

Note: This is an online E Log book recorded to discuss and comprehend our patient's de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.

Here, in this series of blogs, we discuss our various patients' 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 of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end.

I have been given the following case to solve, in an attempt to understand the concept of "Patient clinical analysis data" to develop my own competence in reading and comprehending clinical data, including Clinical history, Clinical findings, Investigations and come up with the most compatible diagnosis and treatment plan tailored exclusively for the patient in question.

CASE :

Chief complaint: 

-Puffiness around eyes since 2months

-Tinglingness all over the head since 2 months

- shortness of breath since 2 months 

-joint pains since 2 months 

History of present illness:

Patient was apparently symptomatic 2 months ago then she developed  puffiness of eyes aggravating with work and cold temperature , revealing on taking rest.  Not progressing, no diurnal variations.

Patient chief complaint of tinglingness all over the head since 2 months aggravating with sleep. No relieving factors. Patient complaints off difficulty breathing.  Aggravating with mild daily routine activities , No seasonal variation, no allergies

Patient complaint of Body pains Over the large joints Since two months, no history of abdominal pains burning micturation deviation of mouth, squint , dysphagia 

•Past history :

Not a known case of DM,HTN,EPILEPSY, CVD,CAD

past history of trauma to left temporal side of head

•Personal history:

Married, daily wage worker 

Normal appetite , regular bowel and bladder movements 

No allergies 

no addictions 

•Family history:  Not Significant 

•Menstrual history: 

Age of menarche: 13 yrs

LMP : 1/12/23

•OBSTETRIC HISTORY: 

Age at marriage:7 yrs

age at 1st child birth:19yrs

G2P2

●General examination:

Patient is conscious coherent cooperative 

Pallor present

No icterus,  cyanosis, clubbing,  lymphadenopathy, malnutrition, dehydration 

•Vitals:

Temperature 98°F

Pulse rate: 84 bpm

Respiratory rate: 22cpm

Blood pressure: 100/60mmHg

SpO2 98%

clinical pictures:

●Systemic examination :

•CVS:

-S1 , S2 heard

-no murmurs

-no thrills 

•Respiratory system:

-trachea central 

-bilateral air entry present 

-normal vesicular breath sounds heard 

•Abdomen examination:

-scaphoid shape

-no tenderness, no palpable mass

-liver and spleen not palpable

-no bowel sounds heard

-no bruits heard 

•Central nervous system:

-patient is conscious 

-speech- normal 

-no focal neurological deficiet 

-higher mental functions are intact

Reflexes: 

                               RIGHT           LEFT 

Biceps -                   ++                    ++

Triceps-                  ++                    ++

supinator-               +                      +

knee -                     ++                     ++

ankle-                      +                       +

•Investigation:

Hemogram:

Glycated Hemoglobin: 

Blood sugar random:

           

 

Post lunch Blood sugar :

Blood sugar fasting  :

Complete urine examination :

Renal function test:

Liver function test:

Blood grouping and Rh tying :

Thyroid profile:

USG neck:

ECG :

X rays:

Color DOPPLER 2D:

•Provisional diagnosis:

     Primary hypothyroidism 

TREATMENT:

 • tab. Neurokind plus

 • tab. Pregabalin 750 mg 

 • tab. Ultracet TID

 • tab. Shelcal OD