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
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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