Case 5

This is an online E log book 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 series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment"

 35 yrs female ,came to opd with complaints of swelling in abdomen since 15 days

History of present illness:

 

Patient was apparently asymptomatic 15 days ago back .

She developed fever which is mild onset ,gradually it is associated with chills and rigor.

Fever has been subsided  taking medication.

-she developed abdominal distension 15 days back 

-patient has suffered from loss of appetite from 10 days ago


Past history:

-No history of chest pain ,palpitations,cold ,cough 

-patient is not suffering with hypertension 

⁃ no history of diabetes,epilepsy,TB,tyroid disorder

⁃ Patient had not undergone any surgeries 

⁃ Blood transfusion undergone in 2nd           pregnancy


   PERSONAL HISTORY:

Diet-mixed

Appetite-loss of appetite 

Bowel and bladder-irregular 

Sleep-normal 

Addiction -no addiction 


FAMILY HISTORY:

No history of DM/HTN/TB/ asthma/ thyroid 

No similar complaints in the family previously 


Treatment history: not significant 


GENERAL EXAMINATION:

-Patient is conscious,coherent,and cooperative 

⁃  pallor present



⁃ No cyanosis 

⁃ No icterus

⁃ No clubbing 

⁃ No lymphadenopathy 

⁃ Malnutrition is present 

⁃ Oedema-absent 

⁃ No Dehydration

VITALS:

Temp -99.5 C/F

Pulse rate -112/min 

Resp rate-18/min

Bp-180/60 

Spo2-99%


Systemic examination:

1.cvs-inspection-chest wall is bilateral systemically 

Palpation -normal 

Auscultation-normal with regular heart beat

S1 S2 heard

No murmurs 


2.respiratory system:

Position of trachea-central,normal bilateral air entry,no Av sound 

Dyspnea is seen ,expiratory wheeze is position in all area 

Breath sound is vascular 


3.abdomen:



  GI tract /mesentery /peritoneal cavity:

-Large lobulated ascites causing peripheral displacement large bowel loops,free ascites

-mild free ascites 

⁃ significant omental thickening

⁃ Mesentric and anterior diaphymatic lymphadenopathy

⁃

4.CNS:

Patient is conscious,

Speech is normal 

Neck stiffness is not seen 

Cranial nerves,motar system,sensory system is not seen.


Investigation:

















Provisional diagnosis:
Chronic liver disease 

Treatment:
1.salt restriction <2.4gms/day
2.fluid restrictions <1l/day
 3. Tab. Aldacrone 50mg /PD/ OD
4. Daily body wt - Abdominal girth measurement 
5. Strict I/o charting 
6. Inj .Neomol 1 gm / IV/ If temp > 101.1 F 
7. Tab . Lasix 40mg /BD

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