65yr old with ascites

E-LOGS GENERAL MEDICINE

 

Roll no 04 

Hi, i am lasya, 5th Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent. This also reflects patients centered care and online learning portfolio. 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 patients clinical problems with collective current best evidence based inputs. Hope this will be informative!

* This is an ongoing case. I am in the process of updating and editing this ELOG as and when required.

A 65 yr old female patient came to OPD with complaints of shortness of breath since 15 days and abdominal swelling since 13 days .

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 20 days back when she developed high grade fever and decreased urine output which lasted for 5 days after taking medicine. She was asymptomatic for 4 days .

Then she again developed abdominal distension and decreased urine output for which she visited a local hospital, where she was told to have some kidney problem ( creatinine -4.6) and was kept on foleys catheter for passing urine .

It then got relieved. 

The patient then started to get abdominal distension and shortness of breath for which they visited a local hospital and were told to refer to our hospital for dialysis and further treatment.

PAST HISTORY: 

K/c/o diabetes and hypertension since 3 yrs .

Not a k/c/o asthma , CAD , TB .

PERSONAL HISTORY: 

*Diet - mixed 

*Appetite - decreased

*Bowel and bladder movements -normal

*Addictions - chronic alcoholic since 30yrs and tobacco smoking since 30 yrs .

*Sleep - normal 

FAMILY HISTORY:

No significant family history.

GENERAL EXAMINATION: 

Conscious and coherent.

Pallor - not seen

Icterus -not seen 

Cyanosis - not seen

Clubbing -not seen

Lymphadenopathy -not seen

Oedema of feet - mild 

Dehydration - mild 

VITALS :

*Temperature -98.4°F

*Pulse rate - 88/min

*Respiration rate - 18/min.

*BP - 90/70

*SpO2 - 98%

*GRBS - 116mg%

SYSTEMIC EXAMINATION: 

*CVS -

S1 and S2 heard 

No thrills and murmurs

RESPIRATORY SYSTEM -

BAE -positive 

Dyspnea - present 

No wheeze

Position of trachea - central

Breath sounds - vesicular

ABDOMEN -

Distended abdomen

Soft , Nontender 

Free fluid - present

CNS -

Conscious

Speech is normal

( NAD )

PROVISIONAL DIAGNOSIS -

 Low SAAG Ascites ( secondary to acute pancreatitis)

Prerenal AKI

With DM and HTN 

With Alcoholic liver disease ?

With SBP ?

INVESTIGATIONS -

TREATMENT -

22/06/2022

1) Fluid restriction - less than 1L/day

2) salt restriction - less than 2gm /day

3) INJ CEFOTAXIME 2gm/IV/TID

4)INJ RANTAC 150mg/IV/OD

5)TAB LASIX 20mg /PO/BD 

6)IVF NS /RL 

7)INJ TRAMADOL 1amp in 100ml /NS/IV

8) TAB ALDACTONE 50mg OD .