CME CASE 1

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

-Tingling 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 tingling all over the head since 2 months aggravating with sleep. No relieving factors.
Patient had neck pain since 2 months and restriction of movement
Patient complaints of 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 micturItion deviation of mouth, squint , dysphagia

Daily routine:

Patient wakes up at 5:00 am
She makes tea for herself and her son and have at 6:00 am
She will do all household work works and prepare lunch till 9 am
At 9 am she will have rice and some curry as breakfast
she will go to work i.e plucking cotton (harvesting) after having breakfast
At 2pm she will have her lunch rice and curry
She will have dinner at 8:00 pm with rice, curry and curd
She will go to sleep by 9:00 pm

- patient is explaining about her stress conditions like:she lost her husband 20 yrs ago from then she is the only person earning in her family , she herself with some money managed her daughter to get married later on after some disputes with her husband she came back to her mother’s house and her daughter is also staying with her.

-Her son completed intermediate he is not willing to do any job or any daily works inspite of all the difficulties his mother facing

-patient is so worried about both her children and to clear the debts she took from family for daily needs as she earns 150 rupees if she goes to work so in a month she will earn only 2000 /-

- By this we can understand the situation of the patient about her family and financial problems.

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