A 60 year old female with Ascites
A 60 year old female with Ascites :
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
INVESTIGATIONS:
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