50F with c/o incomplete breathing, irritation of eye & excessive sweating

E-LOGS MEDICINE 


Hi, I am Arefin Sadat, a final-year MBBS student. This is an E-Log that depicts the patient-centered approach to learning medicine. This E-Log has been created after taking consent from the patient and their relatives. The links that were used by me for understanding the available data on the particular disease have been mentioned below in each post. I hope you learn valuable information after giving it a good read!



November 11, 2022


CASE OF A 50-YEAR-OLD FEMALE


This is a case of a 50-year-old female. She is a higher secondary school teacher and a mother of a 22-year-old girl. This de-identified blog was created after taking informed consent from the patient.


CHIEF COMPLAINTS 

  1. Incomplete breathing for 2 years
  2. Excessive sweating for 2 years
  3. Irritation of eye for 7 years


History of the patient


This patient was reasonably well until the age of 3 years. 

Then she was affected by a breathing problem & after taking local medications, she became well after almost 1.5 years. Later she was admitted into a school located in a hill track area where the temperature was frigid, so she used to catch a cold very often. At the age of 8 years, she was wrongly diagnosed with pleurisy and took treatment for 1 month. After that, she was diagnosed with tonsil, which was swollen & painful in nature. After taking medicine, the tonsil went away at the age of 10. In the meantime, she left the hill tract area and started living in a plain area. She was also affected with typhoid fever at the age of 10, which persisted for 1 month. Later in sep 2020 and 2021, she was affected by Covid-19 for 2 times. After taking medication, the covid symptoms went away, but the breathing problem persisted. She found it incomplete breathing and was aggravated in the afternoon/evening and during work. In Oct 2022, she did a chest x-ray and eco-cardiogram in Cooch Behar, which was suggestive of lung fibrosis and pericardial effusion. Currently, she is using an inhaler.


She also complains of excessive sweating for almost 2 years. Even in the case of sitting under a ceiling fan, she used to sweat.


She also added that she had felt irritation in the eye since 1993, when her eye became reddish in every 3/4 months. After consultation, the doctor told her that she was affected by iritis & was given an eye drop which helped her to get rid of the problem then, but after a long time, she again started facing the same problem since 2014, but this time there is no redness of the eye; only irritation of eye is present—the problem aggravated in the sunlight. In 2014, she went to Hyderabad for treatment, and the doctor said she was suffering from dry eye. In 2021 she went to Kolkata, and there the doctor said that her tear gland was swollen and for this, she was given some medicine for 2 months and was also advised to contact her eye routinely with a cloth soaked in hot water, but the problem didn’t get well.

Here, it is to be noted that her father is affected by an impaired retina and doesn’t see anything clear even in front of him, and also, the patient's uncle is suffering from a damaged retina.


She further added that within the last few years, there was a mentionable increase in her weight, even under diet and exercise. Her family had a history of low blood pressure, but recently both the patient and her mother became hypertensive, and she has been taking antihypertensive medicine since 2021. Both the patient and her mother have been suffering from insomnia for over 6 years, and currently, the patient is taking medication for sleep. She also added that she feels a numb leg after sitting for a while.


This is not a known case of DM, TB, or Epilepsy. 


Surgical History


In 2008, she had an ectopic pregnancy & at that time, her left fallopian tube was removed. In 2009, she developed a stone in her gall bladder & operation was done. In 2012, she experienced a bike accident, and her right-hand ring finger was amputated.


Patient's Diet 


-Breakfast: 9.30 am with rice, pulse, and vegetables.

-Lunch: 2.00 pm with roti, fruits, and oats.

-Dinner: 10.30 pm with oats, vegetable


Family History:


Her father and uncle have impaired retinas, and her mother is a patient of DM, osteoarthritis & allergy. Her aunt has a history of open heart surgery for two times.


Personal History : 


Diet - Mixed.

Appetite - Normal

Bowel- Normal and once a day

Bladder movements - Normal

Addictions - No significant history



Clinical Images:











Clinical Reports:


















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