Case history-9






 A 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 prognosive 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 2 ndpregnancy

   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 

⁃ No pallor 

⁃ 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 ratec-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

questions:
Wt is the cause of ascites?
Where is the fluid come from?

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