A 60yr old female with Ascitis
A 60yr old female Resident of Narketpally who is housewife came to the OPD with cc of Abdominal dissension and tightness since 15 days.
HOPI:
Patient was apparently asymptomatic 10 years back then she went for routine checkup as she was weak to the hospital and diagnosed with Hypothyroidism.She used medication for about 1 year then stopped.Again started medication 3 years back as advised by doctor.
After 3 months she came to KIMS because of giddiness and was diagnosed with Diabetes and Hypertension. For which she used medication for about 1 year and stopped.And started 3 years back.
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 was on medication and stopped.
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).
History of Abdominal distension and tightness since 15 days for which she is admitted .
PAST HISTORY:
No similar complaints in the past.
PERSONAL HISTORY:
Diet: mixed
Appetite: decreased since 15 days.
Sleep: Inadequate ( disturbed sleep all over the night)
Bowel and bladder movements: good
Addictions: No
GENERAL EXAMINATION
Patient was conscious,coherent and cooperative and well orientated to time,place and person.
Pallor - present
No Icterus , Clubbing, Cyanosis, Generalised lymphadenopathy
Bilateral pedal edema present pitting type
Vitals:
Temp: 102 degree at 8 am
Pulse rate:98bpm
Blood pressur:110/80mm Hg
Respiratory rate:18cycles/min
GRBS:174mg/dl
SYSTEMIC EXAMINATION
RESPIRATORY SYSTEM EXAMINATION
Respiratory system:
Inspection:
Symmetrical chest seen
No scars and sinuses
Trachea central
Palpation:
Inspectory findings are confirmed
Palpable sounds are felt
Percussion:
Resonant note present in all lung areas
Ascultation:
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
Tenderness present.
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
CENTRAL NERVOUS SYSTEM EXAMINATION
Higher mental functions intact
Cranial nerves intact
No focal neurological defecits
INVESTIGATIONS:
PROVISIONAL DIAGNOSIS
Ascitis 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)
Tab Dolo 650mg oral.
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