Case of 28 year old female with ascites

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 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.




This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.



I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

A 28 yr old female patient homemaker,came to opd with chief complaints of abdominal distension since 10 days 

Hopi :

The patient was apparently asymptomatic 10 days back she usually wakes up at 7 o clock, on 16th Oct at morning; she noticed abdominal distension which is insidious in onset non progressive associated with SOB ,SOB which increases on eating food and in sitting position and abdomen is more distended at morning times and partially relived on drinking soda and passing stools no h/o vomting, fever ,melena

There is a history of jaundice whuch were 2 episodes when she was 5 year, it was treated with ayurvedic medicine

H/o dengue 15 months back relieved by symptomatic treatment and papaya juice

In january theres a history of urinary tract infection with symptoms of itchiness and increased frequency of urine 10 times during daytime , 3-4 days at night time , went to hospital and there she was diagnosed as diabetic and managed with oral anti diabetic drugs initially and changed to insulin after pregnancy

Due to history of amenorrhea in may, she got herself checked  and diagnosed as pregnant,in june theres an allergic reaction on arms and legs after intake of some vegetable pickle which subside on taking medication and she got aborted with unknown reason

History of vomiting , dizziness on july5 , which was later know that is was due to high sugar,no intervention made for that .

H/o weight loss( approxx:5kg loss from last3 months 

H/o dietary and lifestyle changes after diagnosed with diabetes shifting to brown rice and chapati.

No similar complaints in the past

Noh/o hypertension ,epilepsy,Tb,asthma.

Family history: no h/o diabetes in their relatives, she was born from second degree consanguinous marriage

Menstrual history:

Menarche at age of 15 years , regular 

2-3 pads per day for 3days

After abortion - 20days bleeding, increased to regular,4-5 pads per day for 3days

Diet: mixed with low glycemic index

Appetite :normal,but cannot eat due to discomfort from distension

Bowel and bladder: normal

Sleep: adequate

Addictions: none

General examination

Conscious, coherent ,cooperative oriented to place and time

Patient is poorly built and moderately nourished 

Vitals

On 26/10/21

Pulse rate:62bpm

Bp:100/60mmhg



Pallor- present


Icterus- absent

Clubbing - absent

Cyanosis- absent

Kolionychia- absent

Lymphadenopathy- absent

Edema - absent

SYSTEMIC EXAMINATION:

PER ABDOMEN:

INSPECTION : generalized fullness

Umbilicus:everted

Palpation: cystic feel, no tenderness ,fluid thrill present

Percussion: shifting dullness present

Auscultation: bowel sounds are heard

RESPIRATORY SYSTEM: 

BVBS are present

CVS: S1, S2 heard no murmurs

CNS: NO FND

INVESTIGATIONS-

CBP


CUE

Liver function tests:









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