30 year old female- ASCITIS

30 YEAR OLD FEMALE WITH ABDOMINAL DISTENSION AND BILATERAL PEDAL EDEMA. 

57 year  old female came to casuality with complaints of fever 5days back which was high grade,associated with chills,generalised body pains and is realived on medication.

 C/o burning micturition since 2DAYS which resolved on medication given in outside hospital.

No h/o cold,cough,melanea,giddiness

No h/o hematuria, rashes on the body

No h/o burning micturition. 

Past history:

K/c/o HTN and is on irregular medication 

Not k/c/o Dm,TB, asthma, epilepsy

Vitals: 

Temp: 97.6

PR: 74bpm

BP: 130/90mm hg

RR: 18cpm

CVS: s1s2 heard

RS: BAE+ NVBS+

P/A: soft, non tender, bowels sounds heard

CNS: NFND

Investigations: 

HB:  12.9

Platelets: 25 thousand  /cu mm

Diagnosis:

Viral pyrexia ? Secondary to dengue

A 30 year old woman presented to opd with the complaints of Abdominal distension since 4 months,

Dyspnea at rest since 4 months 

She used to work as a coolie and was married at the age of 18 years. She has given birth to 4 children, 3 daughters and one son(the youngest), all through normal vaginal delivery. Her last delivery was 20 days back and the abdominal distension which she developed during pregnancy was gradually progressive and often felt dyspneic especially on exertion. She even had bilateral lower limbs swelling extending to her knees which resolved on its own. 

On further questioning, she gave a history of non productive cough which lasted for a month prior to her son's delivery 

Obstetric history- P4L4

On examination-She is thin built

Pallor +

Vitals-

PR - 70bpm, normal in volume, regular, no radio-radial or radio femoral delivery 

Bp - 100/70mmhg

Afebrile

Spo2 - 98% on Room air

RR - 20cpm

Systemic Examination- 

Per Abdomen - 

On Inspection: 

Distended 

Umbilicus everted

Palpation-

No tenderness

No palpable organomegaly 

Percussion -

Dull note present in all areas of the abdomen

Fluid thrill present

Bowel sounds present

CVS- S1,S2+

RS- Bilateral vesicular breath sounds +

CNS - Normal

INVESTIGATIONS-

CUE-

ECG-

CHEST X RAY

USG ABDOMEN-

2D ECHO-

CE CT ABDOMEN-

PROVISIONAL DIAGNOSIS

Ascitis secondary to ? Intestinal TB

TREATMENT-

1.Tab.lasilactone 20/50 mg

2.Tab.pan 40 mg /OD

KIMS HOSPITALS,Narketpally

Nalgonda-T.S

1

DEPARTMENT OF GENERAL-MEDICINE

DISCHARGE SUMMARY ***

Name : J ANASURYA 

IPID : 202118783

UHID : 20210815318 

Pay Type : Paying

Age/Gender : 30 Years/Female

Address :Nalgonda

Discharge Type: Relieved

Admission Date: 13/08/2021 03:46 PM

Discharge Date

Date:21/8/2021

Ward:MEDICINE WARD

Unit:5

Name of Treating Faculty

DR. NIKHILESH KRISHNA (INTERN)

DR. ABHIMANYU(INTERN)

DR. RAAGA MEGHANA(INTERN)

DR. DEEPIKA(INTERN)

DR. BHAVYA SREE(INTERN)

DR. VAMSI KRISHNA PGY1

DR. RASHMITHA PGY2

DR. NIKITHA PGY2

DR. HAREEN (SR)

DR. ARJUN KUMAR (AP)

DR. RAKESH BISWAS (HOD)

Diagnosis

ASCITES SECONDARY TO ABDOMINAL TUBERCULOSIS

Case History and Clinical Findings

A 30 year old woman presented to opd with the complaints of Abdominal distension since 4

months,Dyspnea at rest since 4 monthsShe used to work as a coolie and was married at the age of

18 years. She has given birth to 4 children, 3 daughters and one son(the youngest), all through

normal vaginal delivery. Her last delivery was 20 days back and the abdominal distension which she

developed during pregnancy was gradually progressive and often felt dyspneic especially on exertion.

She even had bilateral lower limbs swelling extending to her knees which resolved on its own.On

further questioning, she gave a history of non productive cough which lasted for a month prior to her

son's deliveryObstetric history- P4L4ON EXAMINATION -PATIENT IS THIN BUILT

Pallor +

Vitals-

PR -70bpm, normal in volume, regular, no radio-radial or radio femoral delivery

Bp -100/70mmhg

Afebrile

Spo2 - 98% on Room air

RR - 20cpm

Systemic Examination-

Per ABDOMEN-

On Inspection:DistendedUmbilicus evertePalpation-No tendernessNo palpable organomegaly

Percussion -Dull note present in all areas of the abdomenFluid thrill present

Bowel sounds present

CVS- S1,S2+

RS- Bilateral vesicular breath sounds +

CNS - Normal

Investigation

MANTOUX TEST POSITIVE (INDURATION OF 22MM)

USG ABDOMEN:

-MULTIPLE ENLARGED LYMPHNODES NOTED IN RETROPERITONEUM (PARAAORTIC

&AORTOCAVAL REGIONS) LARGEST MEASURING 30x27 MM.

-GROSS ASCITES (LOCULATED)

CECT ABDOMEN:

-SIGNIFICANTLY ENLARGED RETROPERITONEAL,RETROCRURAL AND ANTERIOR

DIAPHRAGMATIC NODES

-MILDLY ENLARGED MESENTRIC NODES

-LARGE ASCITES WITH INTERNAL SEPTATIONS

-THICKENING OF GREATER OMENTUM

-MILD DIFFFUSE THICKENING OF PERITONEUM

-20x15MM ENHANCING SUBCENTIMETRIC HYPODENSE LESIONS

-MILD LOCULATED LEFT PLEURAL EFFUSION

BLOOD UREA 13-08-2021 08:03:PM

15 mg/dl 

SERUMCREATININE 13-08-2021 08:03:PM-0.6 mg/dl

 SERUM ELECTROLYTES (Na, K, C l) 13-08-2021 08:03:PM

 SODIUM 130 mEq/L 

 POTASSIUM 3.2 mEq/L 

 CHLORIDE 100 mEq/L 

SERUMPROTEIN 13-08-2021 08:03:PM

7.0 g/dl .

 COMPLETE URINE EXAMINATION (CUE) 13-08-2021 08:07:PM

 COLOUR- Pale yellow

 APPEARANCE -Clear

 REACTION- Acidic

 SP.GRAVITY -1.010

 ALBUMIN +

 SUGAR Nil

 BILE SALTS Nil

 BILE PIGMENTS Nil

 PUS CELLS 3-6

 EPITHELIAL CELLS -2-4

 RED BLOOD CELLS- Nil

 CRYSTALS Nil

 CASTS Nil

 AMORPHOUS DEPOSITS-Absent

 OTHERS Nil

HBsAg-RAPID 13-08-2021 08:07:PM

Negative 

Anti HCV Antibodies- RAPID 13-08-2021

08:07:PM-Non Reactive 

SERUM CREATININE 16-08-2021 11:13:PM-0.6 mg/dl 

Treatment Given(Enter only Generic Name)

30/F PRESENTED TO OPD ON 13/8/21 WITH C/O ABDOMINAL DISTENTION AND DYSPNEA SINCE 4 MONTHS

USG ABDOMEN SHOWED-

-MULTIPLE ENLARGED LYMPHNODES NOTED IN RETROPERITONEUM (PARAAORTIC&AORTOCAVAL REGIONS) LARGEST MEASURING 30x27 MM.

-GROSS ASCITES (LOCULATED)

ASCITIC TAP SHOWED LOW SAAG (0.33) , HIGH PROTEIN (5.1) 90% LYMPHOCYTES

CECT ABDOMEN SHOWED-

-SIGNIFICANTLY ENLARGED RETROPERITONEAL,RETROCRURAL AND ANTERIOR DIAPHRAGMATIC NODES

-MILDLY ENLARGED MESENTRIC NODES

-LARGE ASCITES WITH INTERNAL SEPTATIONS

-THICKENING OF GREATER OMENTUM

-MILD DIFFFUSE THICKENING OF PERITONEUM

-20x15MM ENHANCING SUBCENTIMETRIC HYPODENSE LESIONS

-MILD LOCULATED LEFT PLEURAL EFFUSION

-MANTOUX TEST WAS POSITIVE WITH AN INDURATION OF 22MM

-PLANNED FOR OMENTAL/PERITONEAL BIOPSY

ATTENDERS WERE CLEARLY EXPLAINED ABOUT FURTHER MANAGEMENT OPTIONS

(BIOPSY AND ATT AFTER CONFIRMATION OF TB OR EMPIRICAL ATT) AND RISKS ASSOCIATED WITH BOTH THEY WANT TO GO AHEAD WITH EMPIRICAL ATT TRIAL &SO STARTED THE PATIENT ON ATT.

TREATMENT GIVEN:

1)ATT (FDC) 3 TABLETS PER DAY

2)TAB.PAN 40 MG/OD

OBSERVED FOR 2 DAYS AND PATIENT WAS DISCHARGED IN A HEMODYNAMICALLY STABLE

CONDITION AND IS ADVISED TO COME FOR FOLLOW UP AFTER A WEEK

Advice at Discharge

RX

1)ATT (FDC) 3 TABLETS PER DAY FOR 6 MONTHS (HRZE FOR 2 MONTHS + HRE FOR 4 MONTHS)

2)TAB.PAN 40 MG/OD FOR 1 WEEK

3)TAB.BENADON 40MG/OD

4)TAB.ZINCOVIT OD

PLAN TO CONTINUE ATT FOR ANOTHER 3 MONTHS MORE (6+3) IF THE PATIENT IS STILL SYMPTOMATIC

Follow Up-

REVIEW AFTER 1 WEEK/SOS TO MEDICINE OPD WITH LFT REPORT

When to Obtain Urgent Care-

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR

ATTEND EMERGENCY DEPARTMENT.

Preventive Care-

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: 08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language

SIGNATURE OF PATIENT /ATTENDER

SIGNATURE OF PG/INTERNEE

SIGNATURE OF ADMINISTRATOR

SIGNATURE OF FACULTY