August 6th 2022
This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through a series of inputs from the available global online community of experts intending to solve those patients' clinical problems with collective current best evidence-based inputs.
A 60 year old female patient resident of narketpally who is a housewife came with complaints of abdominal distension and tightness since 15 days.
History of present illness:
She was apparently asymptomatic 10 yrs back.
Then she came to our hospital for a routine checkup as she was weak and diagnosed with Hypothyroidism.She used medication for about 1 year then stopped as she was told that it has come to normal.Again started using medication since 3 years as advised by doctor.
After 3 months again she came to our hospital as she had giddiness and was diagnosed with Diabetes and Hypertension for which she used medication for about 1 year and stopped.And started using medication again since 3 yrs.
And 6yrs back she developed SOB for which she went to hospital and took medication. 1 yr later she was diagnosed with Asthma for which she is on medication.
History of pustules all over the body 3 years back took medication and got releived.Similar episode of lesions repeated 8 months back.
History of Chronic Cough not associated with sputum 1 month back and subsided by inhalation (Ipratropium bromide)
Now since 15 days she had abdominal distension and tightness since for which she was frequently visiting our hospital and she was told to admit on 4/8/2022
No history of pain, vomiting.
Past history:
No history of similar complaints in the past.
Personal history:
Diet: mixed
Appetite: decreased since 15 days.
Sleep: Inadequate ( disturbed sleep all over the night)
Bowel Irregular
Bladder Regular
Addictions: No addictions
Family history:
Not significant.
Drug history:
No history of allergy to any drugs
GENERAL EXAMINATION:
Patient was conscious coherent and cooperative
Moderately bulit and nourished
Pallor - present
No Icterus , Clubbing, Cyanosis, Generalised lymphadenopathy
Bilateral pedal edema present pitting type
Vitals:
Temp:Febrile
Pulse rate:80 bpm
Blood pressure:130/70
Respiratory rate: 18 cpm
GRBS:174 mg/dl
SYSTEMIC EXAMINATION:
RESPIRATORY SYSTEM EXAMINATION
Inspection:
Symmetrical chest seen
No scars and sinuses
Trachea central
Palpation:
Inspectory findings are confirmed
Percussion:
Resonant note present in all lung areas
Auscultation:
Breath sounds heard.
CENTRAL NERVOUS SYSTEM EXAMINATION
HMF intact
Cranial nerves intact
No focal neurological defecits
PER ABDOMEN
Inspection:
Abdominal distension
No scars, sinuses, mass visible
Slit like umbilicus
Palpation:
Inspectory findings are confirmed
local rise of temperature is present
Tenderness present.
Fluid thrill absent
Percussion:
Shifting dullness present.
Auscultation
: Normal bowel sounds heard
No bruit heard
CARDIOVASCULAR SYSTEM EXAMINATION
Inspection : Bilaterally symmetrical chest present
No scars, sinuses
No visible pulsations
Palpation:
Inspectory findings are confirmed
Apex beat normal
On Auscultation :
S1 S2 heard
No murmurs or additional heart sounds
Clinical images of patient:
Investigations:
PROVISIONAL DIAGNOSIS
Ascites secondary to chronic liver disease.
TREATMENT:
Tab Lasix 40mg oral BD
Tab Aldactone 50mg oral BD
Inj. Cefotaxime 2g IV BD
Tab Metformin 500mg oral BD
Tab Thyronorm 50mg oral BD
Tab Telma 40mg oral BD
Inj.Neomal 1gm iv (102 degre)
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