GENERAL MEDICINE -E LOG

14 August, 2021

G. Nandini, 3 rd sem

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

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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 cheif complaints of abdominal distension ,dyspnea ,bilateral pedal edema since 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 resolved and b/ L pedal edema resolved on its own. And has history of cough 1 month prior to her son delivery. 

HISTORY OF PAST ILLNESS:

NO H/O  Diabetes, hypertension, Tuberculosis,asthama, 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 lympadenopathy

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 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

OBSERTIC HISTORY :

G4P4L4

INVESTIGATIONS ORDERED :

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

HAEMOGRAM :

LFT:

ECG:

USG ABDOMEN:

CXR-PA :

Haemogram:

Provisinal 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