A 18year old with Shortness of breath, Right sided hearing loss

August 07, 2022

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An 18year old girl from Suryapet came with the complaints of shortness of breath since 2/8/22 morning which increased by the evening. She also has abdominal pain in right upper quadrant and vomitings.

History of presenting illness:

Patient was apparently asymptomatic 3months ago. Then she developed shortness of breath (grade 4) and pedal edema upto the level of below the knees(pitting type) and facial puffiness.

She also had fever and vomitings for which she was taken to a hospital and was said to have some infection for which she was given medication(unknown).

3 days back(on 2/8/2022 morning) she developed shortness of breath which increased by 3pm (grade 4) and went to a Government hospital and then came to our hospital.

She also had pain in the abdomen right upper quadrant which was dull aching type, non radiating associated with 2 episodes of vomiting which was non projectile, non bilious, associated with nausea and with food as content.

Patient also complaints of decreased hearing in right ear since 4 years associated with ringing sensation.

History of trauma to right ear 4 years ago.

Past history:

Not a k/c/o hypertension, diabetes, asthma, epilepsy, CAD, Thyroid disorders.

Personal history:

She has normal appetite, takes vegetarian diet, bowel and bladder movements are regular, sleep is adequate and no addictions.

Daily routine:

She wakes around 7am in the morning, does house chores like cleaning, have her tea at 8am and her breakfast at 9am. She resumes with her household work and eats her lunch at 2pm, watches TV and takes a nap. Later in the evening she plays with her brothers’ kids and eats her dinner at 9pm and sleeps at 11pm.

Family history:

No member of the family has similar complaints

General examination

She is conscious, coherent and cooperative

She is ill built and poorly nourished

She has pallor