A 60 year old female with Ascites

 

A 60 year old female with Ascites :


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 WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT .

 A 60yr old female Resident of Narketpally who is housewife came to the OPD with chief complaints of Abdominal distension and tightness since 15 days.

HOPI:

Patient was apparently asymptomatic 10 years 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 Hypertensionfor  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 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

No significant family history

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

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 

No local rise of temperature

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

CENTRAL NERVOUS SYSTEM EXAMINATION 

Higher mental functions intact 

Cranial nerves intact 

No focal neurological defecits

  






After Ascitic Fluid Tap:



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)  
 
10/8/22 : 
INFLAMMATORY PERITONITIS 
Secondary to CHRONIC LIVER DISEASE 

11/8/22 :
INFLAMMATORY PERITONITIS 
Secondary to CHRONIC LIVER DISEASE 
Paracentesis done

12/8/22
INFLAMMATORY PERITONITIS 
Secondary to CHRONIC LIVER DISEASE 
Investigation:- Endoscopy





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