GENERAL MEDICINE CASE

 B.VAISHNAVI

5th SEMESTER

ROLL NO. 22

This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.

A 47 year old female came to the opd with chief complains of  abdominal distension and abdominal pain since 2 months

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 2 months back, then she developed abdominal distension associated with pain, bilateral pedal edema associated with pain in both lower limbs. Had decreased urine output and burning micturition. H/o shortness of breath, decreased appetite, weight loss. For which she visited a local hospital, all the symptoms subsided but abdominal distension and pain abdomen remained. 

HISTORY OF PAST ILLNESS:

k/c/o DM since 6 years

k/c/o HTN since 2 months

k/c/o Hypothyroidism since 2 months

not k/c/o Epilepsy, asthma, CAD

no h/o surgeries

TREATMENT HISTORY:

For DM - INJ MIXTARD INSULIN

For Hypothyroidism- TAB. THYRONORM 100mcg/OD

For Hypertension- TAB. TELMA 40 mg PO/OD

PERSONAL HISTORY:

Appetite - normal

Mixed diet

Sleep- adequate

Bowel and bladder movements - regular

No drug allergies

FAMILY HISTORY:

History of diabetes is present

GENERAL EXAMINATION:

Patient is conscious, coherent, cooperative

Absence of pallor, icterus, cyanosis, lymphadenopathy. 
Mild pedal edema is seen

VITALS:
 
Temperature:Afebrile

Pulse rate:98 bpm

Respiratory rate: 22 cpm

BP: 110/70 mm of hg

Spo2:98% at room air

GRBS: 540 mg%

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

Thrills absent

S1, S2 heard

No murmurs

RESPIRATORY SYSTEM:

Normal vesicular breath sounds

Position of trachea is central

No dyspnoea 

No wheeze

ABDOMEN 

shape of abdomen- distended

No tenderness

No palpable mass

Normal hernial orifices

No free fluid

No bruits

Liver and spleen are not palpable

Bowel sounds heard






CENTRAL NERVOUS SYSTEM:

Patient is conscious

Speech-normal

No signs of meningeal irritation

Motor and sensory system is intact

PROVISIONAL DIAGNOSIS:

ASCITIS 

INVESTIGATIONS:









TREATMENT:

INJ HAI SUBCUTANEOUS, ACCORDING TO GRBS

TAB TELMA 40 mg PO/OD

GRBS MONITORING 6 HRLY

INJ LASIX 40 mg/IV/BD

TAB OROF6R ×T PO/BD

TAB NODOSIS 500 mg PO/BD

TAB SH6LCAL D3  PO/OD

INJ ERYTHROPOIETIN 4000 IU/SC(WEEKLY ONCE) 





















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