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

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

 

This is an online e log book to discuss our patients' identified health data shared after taking his/ her/ guardians consent. Here we discuss our individual patients' problems through a series of  inputs from an available global online community of experts with an aim to solve those patients' clinical problems with the collective current best evidence based inputs. This e- log also reflects a patient centered learning portfolio.  

 

A 30 years old woman Presented to the OPD  with chief complaints of abdominal distension , dyspnea, bilateral pedal edema. 

 

HISTORY OF PRESENT ILLNESS :

 

A 30 year old woman presented to the OPD with chief complaints of abdominal distension ,dyspnea ,bilateral pedal edema for 4 months. She is a mother of 4 children with 3 daughters and one son. Post NVD of  her son her abdominal distension did not resolve and b/ L pedal edema resolved on its own. And has a history of coughing 1 month prior to her son's delivery. 

 

HISTORY OF PAST ILLNESS:

 

NO H/O  Diabetes, hypertension, tuberculosis,asthma, epilepsy, thyroid, CAD, CVD

 

PERSONAL HISTORY :

 

  • Mixed diet

  • Normal appetite

  • Adequate sleep

  • Regular bladder and bowels movements

  • No addictions

 

FAMILY HISTORY :

 

No similar complaints in the family. No history of diabetes, hypertension,asthma, TB, CAD, CVD

 

GENERAL EXAMINATION : 

 

  • Patient was conscious, coherent, co - operative. 

  • Well oriented to time, place, and person. 

  • Moderately built and moderately  nourished. 

  • pallor - present

  • No clubbing

  • No cyanosis

  • No lymphadenopathy

  • No edema

  •  

VITALS :

 

  • PR : 78 bpm, regular

  • Bp : 100/60 mm of Hg

  • GRBS : 88mg /dl

  •  

 

SYSTEMIC EXAMINATION:

 

PER ABDOMINAL EXAMINATION :

 

INSPECTION -

 

  • Shape - Distended

  • Umbilicus -everted

  • Movements with respiration - equal in all quadrants rises with inspiration  and falls during expiration .

  • No visible pulsations

  • No visible scars or sinuses seen

  • No engorged veins

 

PALPATION :

 

  • No local rise of temperature

  • No tenderness in any quadrants of abdomen, liver and spleen - impalpable ( no organomegaly) 

 

PERCUSSION :

 

  • Dullness all over the abdomen is present. 

  • Liver dullness present at right 5th intercostal space. 

  •  

AUSCULTATION :

 

 Bowel sounds present 

 

 

CVS EXAMINATION :

 

  • S1, S2 heard

  • No murmurs

 

RESPIRATORY SYSTEM EXAMINATION :

 

  • Trachea - midline

  • Bilateral air entry present

  • Normal Vesicular breath sounds heard

  • No additional sounds

 

CNS EXAMINATION :

 

  • Gait - normal

  • Sensations - present

  • Cranial nerves - intact

  • Reflexes - preserved

 

OBSTETRIC HISTORY :

 

G4P4L4

 

INVESTIGATIONS ORDERED :

 

ECG, CXR - PA, USG Abdomen for line echotexture, Haemogram, LFT, RFT, Complete urine examination. 

 


ECG 


CXR-PA


USG- ABDOMEN


HEMOGRAM






PROVISIONAL DIAGNOSIS: Ascites secondary to intestinal TB ? 

TREATMENT:

1.Tab.lasilactone 20/50 mg

2.Tab.pan 40 mg /OD

3.Daily weight and abdominal growth measurement

4.Bp/pR/Temp/Spo2 monitoring


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