17year old female with PCOD
December 17,2022.
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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 competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan.
A 17year old unmarried female resident of West Bengal came to our hospital on 17/12/2022 with the complaints of
Acne since 2years
Dark pigmentation of bilateral armpits since 2years
Hairfall since 2years
Watering of eyes(on and off) and itching of eyes since 2years
Decreased menstrual flow since June 2022
Facial hair growth since June 2022
Jaw pain since October 2022
HISTORY OF PRESENT ILLNESS:
Patient was apparently normal 2years ago then she noticed severe acne breakouts, dark pigmentation of bilateral armpits, hairfall and watering of both eyes (on and off) and itching of eyes.
She had decreased blood flow during her cycles since 6months.It is associated with pain.Not associated with clots.
H/o white discharge since 7years
No H/O burning micturition, fever
No H/O pain abdomen and weight gain
No H/oand jaw pain aggravated with movements.
Previous record of the patient.
Thanks for the Amili Dutta for the previous detailed history.
https://amilidutta137.blogspot.com/2022/12/17f-suffering-from-pcod.html
N/k/c/o DM ,HTN ,TB ,EPILEPSY ,ASTHMA
K/c/o PCOD since Feb 2022 and took online consultation for it and was given T. Metformin 500mg(used only 2 tablets and stopped)
K/c/o Allergic Rhinitis since last 10years
H/O scabies present and consulted dermatologist and was treated 1yr ago and in this year.
No previous blood transfusions
PERSONAL HISTORY:
Student ,studying +2
Appetite : Normal
Diet : Mixed
Sleep : Adequate
Cardiovascular System : S1, S2 heard, no murmurs
Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.Position of trachea central.
Central Nervous System : Conscious; Speech normal ; Motor and sensory system examination is normal, Gait is normal.
Per abdomen : soft, non tender. No organomegaly.
Referrals:
PROVISIONAL DIAGNOSIS:
PCOD with acanthosis nigricans with telogen effluvium with Allergic rhinitis
TREATMENT:
EYE DROPS BEPOSTINE
EYEDROPS LUBREX
ACNE MOIST UV BD
TAB TECZINE 5mg SOS if itching
TRETIN 0.025% ointment L/A OD
TAB. MONTAIR LC BD
DUONASE NASAL SPRAY (2puffs-2puffs)
Avoid allergens.
19/12/22
17 year old female
GM unit 4
Super speciality ward
Day- 3
S
Burning sensation over left cheek subsided
O
Pt is conscious coherent and cooperative
Temp- 97.4F
Bp- 120/80mmHg
Pr- 73bpm
RR- 19cpm
Cvs-S1 S2+
Rs- BAE+
CNS- HMF intact
P/a- soft, non tender
A
PCOD with acanthosis nigricans with telogen effluvium with Allergic rhinitis
P
Eye drops Bepostine
Eye drops Lubrex
Acne moist L/A BD
T Teczine 5mg sos
Oint Tretin 0.025% L/A BD
T Montair LC BD
Duonase nasal spray 2 puffs BD
Avoid allergens
20/12/22
17 year old female
GM unit 4
Super speciality ward
Day- 4
S
Burning sensation over left cheek subsided
O
Pt is conscious coherent and cooperative
Temp- 98F
Bp- 120/80mmHg
Pr- 78bpm
RR- 16cpm
Cvs-S1 S2+
Rs- BAE+
CNS- HMF intact
P/a- soft, non tender
A
PCOD with acanthosis nigricans with telogen effluvium with Allergic rhinitis
P
Eye drops Bepostine
Eye drops Lubrex
Acne moist L/A BD
T Teczine 5mg sos
Oint Tretin 0.025% L/A BD
T Montair LC BD
Duonase nasal spray 2 puffs BD
Avoid allergens
21/12/22
17 year old female
GM unit 4
Super speciality ward
Day- 5
S
1st lower molar tooth pain on the right side .
O
Pt is conscious coherent and cooperative
Temp- 98F
Bp- 110/70mmHg
Pr- 82bpm
RR- 14cpm
Cvs-S1 S2+
Rs- BAE+
CNS- HMF intact
P/a- soft, non tender
A
PCOD with acanthosis nigricans with telogen effluvium with Allergic rhinitis
P
Eye drops Bepostine
Eye drops Lubrex
Acne moist L/A BD
T Teczine 5mg sos
Oint Tretin 0.025% L/A BD
T Montair LC BD
Duonase nasal spray 2 puffs BD
Avoid allergens
22/12/2022
17 year old female
GM unit 4
Super speciality ward
Day- 6
S
Pain in the 1st lower molar tooth on the right side -subsided
O
Pt is conscious coherent and cooperative
Temp- 97.2F
Bp- 120/70mmHg
Pr- 89bpm
RR- 17cpm
Cvs-S1 S2+
Rs- BAE+
CNS- HMF intact
P/a- soft, non tender
A
PCOD with acanthosis nigricans with telogen effluvium with Allergic rhinitis
P
Eye drops Bepostine
Eye drops Lubrex
Acne moist L/A BD
T Teczine 5mg sos
Oint Tretin 0.025% L/A BD
T Montair LC BD
Duonase nasal spray 2 puffs BD
Avoid allergens
Discharged: on 22/12/2022
