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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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