38/f c/o facial puffiness, weight gain and purple striae
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I have 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.
38 yr old female came with complains of facial puffiness since 2 months
Shortness of breath since 1 month
Weight gain since 4 months
Patient was apparently alright 4 months ago then she development erythematous lesions all over the body for which she used medication for 1month from outside hospital following which the lesions subsided
Pt c/o increased appetite since 4 months and unintentional weight gain since 4 months
Pt c/o facial puffiness and swelling all over the body
C/o shortness of breath since 1 month which aggravated on less than ordinary activity relieved on rest. Orthopnea + pnd+
Associated withb/l pedal edema pitting type upto knees since 2 months
No c/o chest pain palpitations, profuse sweating
C/o dark color strech marks over the abdomen and over the axilla since 1 month
C/o urgency, hesitancy and dribbling of urine since 1 week
C/o erythematous lesions over the groin since 1 week associated with burning micturation
K/c/o hypothyroidism since 1 year on T thyronom 25 mg po od
Not taking medication since 2 days
Not a k/c/o htn, cva, cad, tb, asthma, sepsis
Menstrual history
Lmp : POST HYSTERECTOMY DONE 6 YRS AGO
Age of menarche 13 yrs
3 to 4 days / 28 to 30 days regular cycle
2 to 3 pads per day, not associated with pain and clots
Marital history
Married at 22 yrs, non consanguineous marriage
Obstetric history
1st preg conceived spontaneously 2 yrs after marriage FTLSCS i/v/o malpresentation
17 yrs male 4 kgs alive and healthy
2nd pregnancy conceived spontaneously immediately after last child birth, ftlscs I/v/o NPOL, 16 YRS, male 2.5 kgs alive and healthy
Daily routine
General examination
Pt is c/c/c
No Pallor icterus clubbing
On examination
Gynecology opnion was taken on 19/1/24
O/E
Pt is obese( central obesity +)
Facial puffiness present
Purple striae present over abdomen and axillae
Erythematous ptechiae present all over the body
B/l pitting edema present below knee
Facial chloasma present
Abdominal examination
P/a soft, non tender, obese abdominal wall, purple steriae of 1 cm breadth present all over the abdomen
Below umbilical Midline vertical scar present scar healthy
P/s vault clear watery discharge seen , healthy
Vagina dry
BME vault intact b/l fornices free
Endocrine referal done on 19/1/24
Derma referal was done on 19/1/24 i/v/o? Crushing syndrome
C/o painful skin lesions over b/l arms, b/l legs ,chest, abdomen since 2 1/2 months( initially on arms followed on legs)
C/o itchy skin lesions over genitals since 6 months
C/o fever on and off since 2 months c/o burning micturation since 20 days
H/0 intake of new oral medication prior to onset of petechiae(documentation not available)
O/E multiple well defined pin point petechiae (blanchable) notes over b/l upper and lower linbs
Multiple erythematous striae noted over labia major
Adviced: BT, CT, fbs, plbs, swab for vaginal discharge
Provisional diagnosis
purpura for evaluation, vulvo vaginal candidiasis, striae rubra
Urology referal done on 19/1/24 i/v/o dribbling, urgency, hesitancy of urine
Dysuria since 1 1/2 month
Dribbling of urine +
Freq/nocturia :3-4/1-2 times
Poor stream+
Occasional urge incontinence +
Stress incontinence +
Sense of incomplete evacuation +
O/E vulvo vaginitis+
No evidence of stress incontinence
Urethra dilated upto 9 hegar
Advice
Obg opnion
Usg kub with pvr
Speculum examination
Review with reports and gyn opnion to urology department
Gynecology opnion was taken on 19/1/24
O/E
Pt is obese( central obesity +)
Facial puffiness +
Purple striae present over abdomen and axillae
Erythematous patchee present all over the body
B/l pitting edema present below knee (grade 2)
Facial chloasma present
Per abdomen :
soft nontender, obese abdominal wall, purple steriae of 1 cm breadth present all over the abdomen
Below umbilical Midline vertical scar present scar healthy
Per speculum examination:
vault: clear watery discharge seen , healthy
Vagina: dry
BME (bimanual examination):
vault intact
b/l fornices free
Advice fbs, plbs, hba1c urine for culture and sensitivity, hvs and review with reports
Patient was complain of itchy lesions on right hand
Derma referal was done in view of lesions
C/0 itchy burning skin lesions over right hand since one day
No h/o insect bite, tropical applied
Generalized itching all over the body
O/E multiple Erythematous papules noted over rt forearm near to wrist
Echymosis noted over b/l forearms
Provisional diagnosis
Vulvovaginal candidiasis +striae rubrum + steroid induced purpura +irritant contact dermatitis + tinea corporis +echymosis
Treatment
Lulifin cream local application for 1 week
Tab teczine 5 mg od for 1 week
Liquid paraffin local application bd for 2 weeks
Electronic summary
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