GENERAL MEDICINE -AUGUST 2021

SUPRIYA GAGIREDDY 42

Hi,I am supriya 3rd sem medical student.This is an online elog book to discuss our patients de-identified health data shared after taking his/her/guardians signed informed consent.Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.This E-log book reflects my patient centered online learning portfolia.

Under the guidance of Dr.Sai Deepika mam[intern]

A 30 year old female daily labourer by occupation came to the OPD with chief complaints of 

Abdominal distention since 4 months

Dyspnea since 4 months

Bilateral pedal edema since 4 months


HISTORY OF PRESENT ILLNESS:

The patient presented with Abdominal distension,Dyspnea,Bilateral pedal edema since 4 months.Bilateral pedal edema resolved on its own.Her abdomial distension hasnt been resolved after post normal vaginal delivery of son.

She is a mother of 4 children -3 daughters and 1 son.

H/O Nonproductive cough 1 month prior to her son delivery.


HISTORY OF PAST ILLNESS:

Not a known case of Hypertension,Diabetes mellitus,Thyroid disorder.

No H/O CAD,CVA


PERSONAL HISTORY:

Married

Occupation-Daily labourer

Appetite-normal

Mixed diet

Bowels-Regular

Adequate sleep

Micturition-Normal

No Addictions

TREATMENT HISTORY:

No specific treatment history.

FAMILY HISTORY:

No specific family history.

OBSTETRIC HISTORY:

Age at marriage:18 years

No.of living children:4


GENERAL EXAMINATION:

Patient was conscious,coherent,co-operative .

Well oriented to time,place and person.

Moderately built and moderately nourished.

PALLOR-Present

No Icterus

No Cyanosis

No Clubbing

No Lymphadenopathy

No Edema


VITALS:

Temperature:Afebrile

Pulse rate:78bpm,Regualar

Blood pressure:100/60mmHg

GRBS:88mg/dl


SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

S1 and S2 heard

No thrills

No cardiac murmurs


RESPIRATORY SYSTEM:

Trachea-midline

BAE+

Normal vesicular breathe sounds heard


PER ABNOMENAL EXAMINATION:

INSPECTION

Distended shaped abdomen

Umbilicus everted

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

No visible pulsations

No engorged veins

No visible scars or sinuses seen

Fluid thrills present

PALPATION

No local rise of temperature

No tenderness  in any quadrants of abdomen,liver,and speen-impalpable 

PERCUSSION

Liver dullness + Right 5th ICS

Dullness all over the abdomen

AUSCULTATION

Bowel sounds present

CNS EXAMINATION:

Conscious

Normal speech

No neck stiffness

No kerning's sign

Cranial nerves:Intact

Senasations present

Gait:Normal

INVESTIGATIONS:

HEMOGRAM

Hemoglobin=10.3gm/dl

RBC count=3.88millions/cumm

Total leucocyte count=6800cells/cumm

Neutrophils=65%

Lymphocytes=15%

Eosinophils=05%

Monocytes=05%

Basophils=00%

Platelets=1.4lakhs/cumm

PCV=31.7

MCV=81.7

MCH=26

MCHC=31.9

RDW-CV=14.5

RDW-SD=43.8

APTT:37secs

Bleeding time:2mins 30secs

Clotting time:5mins 

PT:18secs

INR:1.33


LIVER FUNCTION TEST:

Total bilirubin:0.67mg/dl

Direct bilirubin:0.20mg/dl

SGOT:15 IU/l

SGPT:10 IU/l

ALP:246 IU/l

Total proteins :7gm/dl

Albumin:3.8gm/dl

A/G Ratio:0.78


RENAL FUNCTION TEST:

Urea :15mg/dl

Creatinine : 0.6mg/dl

Sodium : 130mEq/L

Potassium : 3.2 mEq/L

Chloride : 100 mEq/L

Pus cells :3.4

Albumin : +


RANDOM BLOOD SUGAR

RBS - 117mg/dl


ASCITIC FLUID PROTEIN SUGAR

Sugar - 79mg/dl

Protein - 5.1g/dl


ASCITIC FLUID FOR LDH

LDH - 419 IU/L


SEROLOGY - NEGATIVE


ASCITIC FLUID AMYLASE



ESR


COMPLETE URINE EXAMINATION


COLOUR DOPPLER 2D ECHO



ECG


 ULTRASOUND REPORT



      CHEST X RAY



PROVISIONAL DIAGNOSIS

ASCITES  decreased evaluation

Ascites secondary to ? Intestinal TB


TREATMENT

Tab Lasilactune 20/50 mg BD

Tab PAN 40mg OD

Daily wt of abdominal growth monitoring

BP/PR/Temperature/SpO2 monitoring















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