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A CASE OF 35 YR OLD FEMALE

This is an online E log book to discuss our patient's de-identified health data shared after taking his /her/guradian's consent.
This E log book also reflects my patient-centered online learning portfolio and your valuable inputs in the comment box below.

Date of Admission: 21/11/2021 

A 35 yr old female , homemaker by profession ,mother of 2 kids came to the OPD with
Chief complaints of :

▪︎Loss of appetite since 1 month 
▪︎Abdominal distention since 15 days 
▪︎Shortness of breath since 10 days

History of present illness:

▪︎Patient was asymptomatic 1month back and then had a significant loss of appetite , developed fever which was insidious on onset and gradually progressive associated along with chills and rigor .
Fever subsided on taking medication
 
▪︎Patient has c/o abdominal distension since 15 days

▪︎Shortness of breath since 10 days 
SOB grade II - III 
Not along with orthopnea or PND 

▪︎C/o of loss of appetite 

▪︎No complaints of 
Chest pain
Palpitation
Cough and cold 

History of past illness:

▪︎Not a known case of DM/Asthma /TB/HTN/Thyroid/CKD/CAD

▪︎History of blood transfusion during 5th month of her second pregnancy 

▪︎Patient got tested positive for typhoid 10 days ago 
Treatment was done in a hospital outside but as fever didn't subside much on medicines, the patient was referred here 

Patient is also consuming a tonic for increasing appetite since then

Personal history:

▪︎Diet: Mixed 
▪︎Appetite: Decreased 
▪︎Bowel and bladder movements: Normal now 
Patient had episodes of diarrhea 1 month back for which she underwent treatment in a outside hospital 
▪︎Sleep: Normal
▪︎Addictions: No addictions 

Surgery History:
Patient underwent Tubectomy 6 months after birth of her second child 

Family History:
Insignificant 

General Examination:
O/E, patient is conscious, coherent and cooperative 

Vitals:

▪︎BP: 80/60 mmHg
▪︎PR:112  bpm
▪︎RR: 20 cpm 
▪︎Spo2: 99% at RA 
▪︎GRBS: 115 mg/dl 
▪︎Temperature: 101° F 

Systemic Exmaination:
CVS:
▪︎S1,S2 heard 
no murmurs 

Respiratory system:
▪︎NVBS - present 
▪︎BAE - present 

Per Abdominal:
▪︎Abdominal girth-74 cm s 
▪︎Bowel Sounds -present 
▪︎No engorged veins observed 
▪︎Fluid thrills- present 
▪︎Shifting dullness-absent 
▪︎No Organomegaly 

CNS:
▪︎NAD and HMF intact  

Clinical Images:



Provisional Diagnosis:
Low SAAG? Peritoneal Tuberculosis 

Investigation:

21/11/2021

22/11/2021
        
                   Colour Doppler 

                             ECG

         
                 Liver Function Test 

          Serum Electrolytes (Na,K,Cl)

                   Serum Creatinine 

                        Blood Urea 

                    Uric Acid Serum 

                Blood Sugar-Random 

                       Hemogram 

          Blood Grouping and RH type 

         Complete Urine Examination 


23/11/2021

        CT Scan-Abdomen and Pelvis 

                       Ultrasound 


         Investigation result of tests                   performed on 22/11/2021

Treatment : 
▪︎Salt restriction less than 2.4 g/day
▪︎Fuild restriction 
▪︎Tab ALDACTONE 50 MG /PO/OD
▪︎INJ NEOMOL 1 GM /IV ... if temperature goes more than 101° F 
▪︎2 TSP BF PROTEIN POWDER IN 100ML MILK PO/TID 

In "SOAP" format

24/11/2021

Subjective: fever spike present 
Objective:
Patient is conscious, coherent and cooperative 
Vitals:
▪︎PR: 104 bpm
▪︎BP:100/70 mmHg 
▪︎RR: 18 cpm
▪︎Temperature:99.5° F 
▪︎GRBS: 124 mg/dl

Systemic Examination:

CVS 
▪︎S1 S2 heard 
no murmurs 

Respiratory System  : 
▪︎NVBS present  
▪︎BAE present  

Per Abdomen: 
▪︎Abdominal girth - 79 cm 
▪︎Bowel sounds + 
▪︎No engorged veins 
▪︎Fluid thrill + 
▪︎Shifting dullness absent 
▪︎No organomegaly 

Wt : 35 kgs 

CNS:
▪︎NAD, HMF INTACT

Assessment
?Abdominal TB

Plan:

Treatment
▪︎Salt restriction less than 2.4 g/day 
▪︎Fuild restriction less than 1 lit/ day 
▪︎Tab ALDACTONE 50 MG /PO/OD
▪︎INJ NEOMOL 1 GM /IV ...IF TEMP MORE THAN 101° F 
▪︎Tab LASIX 40 MG /PO/OD 
▪︎TAB PCM 650 MG /PO/OD 
▪︎2 TSP BF PROTEIN POWDER IN 100 ML MMILK PO/TID 
▪︎2 Egg white / day 
▪︎Tab OROFER XT /PO/OD  

      CELL COUNT OF ASCITIC/  PERITONEAL FLUID            


25/11/2021

Subjective: fever spike present 
Objective:
Patient is conscious, coherent and cooperative 
Vitals:
▪︎PR: 88 bpm
▪︎BP:100/70 mmHg 
▪︎RR: 18 cpm
▪︎Temperature:99° F 
▪︎GRBS: 124 mg/dl

Systemic Examination:

CVS 
▪︎S1 S2 heard 
no murmurs 

Respiratory System  : 
▪︎NVBS present  
▪︎BAE present  

Per Abdomen: 
▪︎Abdominal girth - 71 cm 
▪︎Bowel sounds + 
▪︎No engorged veins 
▪︎Fluid thrill + 
▪︎Shifting dullness absent 
▪︎No organomegaly 

Wt : 30 kgs 

CNS:
▪︎NAD, HMF INTACT

Assessment
?Abdominal TB

Plan:

Treatment
▪︎Salt restriction less than 2.4 g/day 
▪︎Fuild restriction less than 1 lit/ day 
▪︎Tab ALDACTONE 50 MG /PO/OD
▪︎INJ NEOMOL 1 GM /IV ...IF TEMP MORE THAN 101° F 
▪︎Tab LASIX 40 MG /PO/OD 
▪︎TAB PCM 650 MG /PO/OD 
▪︎2 TSP BF PROTEIN POWDER IN 100 ML MMILK PO/TID 
▪︎2 Egg white / day 
▪︎Tab OROFER XT /PO/OD  
▪︎Tab nitrofurantoin 100mg po/bd 

             PROTHROMBIN TIME 
 

26/11/2021

Subjective: fever spike present 
Abdomen distended tense , everted  umbilicus 
Increased abdominal girth and weight


Objective:
Patient is conscious, coherent and cooperative 
Vitals:
▪︎PR: 88 bpm
▪︎BP:90/60 mmHg 
▪︎RR: 18 cpm
▪︎Temperature:99° F 
▪︎GRBS: 107 mg/dl

Systemic Examination:

CVS 
▪︎S1 S2 heard 
no murmurs 

Respiratory System  : 
▪︎NVBS present  
▪︎BAE present  

Per Abdomen: 
▪︎Abdominal girth - 77 cm 
▪︎Bowel sounds + 
▪︎No engorged veins 
▪︎Fluid thrill + 
▪︎Shifting dullness absent 
▪︎No organomegaly 

Wt : 32 kgs 

CNS:
▪︎NAD, HMF INTACT

Assessment
?Abdominal TB

Plan:

Treatment
▪︎Salt restriction less than 2.4 g/day 
▪︎Fuild restriction less than 1 lit/ day 
▪︎Tab ALDACTONE 50 MG /PO/OD
▪︎INJ NEOMOL 1 GM /IV ...IF TEMP MORE THAN 101° F 
▪︎Tab LASIX 40 MG /PO/OD 
▪︎TAB PCM 650 MG /PO/OD 
▪︎2 TSP BF PROTEIN POWDER IN 100 ML MMILK PO/TID 
▪︎2 Egg white / day 
▪︎Tab OROFER XT /PO/OD  
▪︎Tab nitrofurantoin 100mg po/bd  

                    FEVER CHART 

             LIVER FUNCTION TEST

                  ZN STAIN REPORT 


                WET MOUNT REPORT 



27/11/2021

Subjective: fever spike present 
Night and today morning 

Objective:
Patient is conscious, coherent and cooperative 
Vitals:
▪︎PR: 116 bpm
▪︎BP:80/50 mmHg 
▪︎RR: 18 cpm
▪︎Temperature:100.6° F 

Systemic Examination:

CVS 
▪︎S1 S2 heard 
no murmurs 

Respiratory System  : 
▪︎NVBS present  
▪︎BAE present  

Per Abdomen: 
▪︎Soft
▪︎Abdominal girth - 73 cm 
▪︎Bowel sounds + 
▪︎No engorged veins 
▪︎Fluid thrill + 
▪︎Shifting dullness present
▪︎No organomegaly 

Wt : 31 kgs 

CNS:
▪︎NAD, HMF INTACT

Assessment
?Abdominal TB

Plan:

Treatment
▪︎Salt restriction less than 2.4 g/day 
▪︎Fuild restriction less than 1 lit/ day 
▪︎Tab ALDACTONE 50 MG /PO/OD
▪︎INJ NEOMOL 1 GM /IV ...IF TEMP MORE THAN 101° F 
▪︎Tab LASIX 40 MG /PO/OD 
▪︎TAB PCM 650 MG /PO/OD 
▪︎2 Egg white / day 
▪︎Tab nitrofurantoin 100mg po/bd  

                  T3,T4,TSH LEVELS 
              LIVER FUNCTION TEST 

▪︎Anti Tuberculosis Therapy  (ATT) started.

Plan for discharge 





        






     



























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