A 55 year old Woman with Abdominal distension
A 55 year old woman Resident of Narketpally who is a housewife by occupation came to the OPD with chief complaints of Abdominal distension and tightness since 16 days.
HOPI:
Patient was apparently asymptomatic 10 years back.
10years back she came to our hospital with chief complaints of weakness and was diagnosed was with Hypothyroidism, used medication for about 1 year and she was normal,and was told to stop using medications . Again started using medication since 3 years as advised by doctor.
And 10 years back with a gap of 3 months she came back with complaints of giddiness and was diagnosed with Diabetes and Hypertension for which she used medication for about 1 year and stopped using medication .And started using medication again since 3 yrs.
And 6yrs back she developed SOB for which she went to hospital and took medication. 1 yr later she was diagnosed with Asthma for which she is on medication.
History of pustules all over the body 3 years back took medication and got releived.Similar episode of lesions repeated 8 months back and she took medication.
History of Chronic Cough not associated with sputum 1 month back , subsided on inhalation(Ipratropium bromide)
Abdominal distension and tightness since 16 days for which she was frequently visiting our hospital and she was admitted on 4/8/2022
No history of pain, vomiting.
Complaints of dry cough since yesterday
PAST HISTORY:
No similar complaints in the past.
PERSONAL HISTORY:
Diet: mixed
Appetite: decreased since 16 days.
Sleep: Inadequate ( disturbed sleep all over the night)
Bowel - Irregular
Bladder - Regular
Addictions - Chewable Tobacco since 20 years
FAMILY HISTORY
No significant family history
DRUG HISTORY
No history of allergy to any drugs
GENERAL EXAMINATION
Patient was conscious coherent and cooperative
Moderately bulit and nourished
Pallor - present
No Icterus , Clubbing, Cyanosis, Generalised lymphadenopathy
Bilateral pedal edema present ,pitting type
Vitals:
Temp: Febrile(99.7°F)
Pulse rate:80 bpm
Blood pressure:120/60
Respiratory rate: 18 cpm
GRBS:174 mg/dl
SYSTEMIC EXAMINATION
RESPIRATORY SYSTEM EXAMINATION
Inspection:
Symmetrical chest seen
No scars and sinuses
Trachea central
Palpation:
Inspectory findings are confirmed
Percussion:
Resonant note present in all lung areas
Ascultation:
Normal Vesicular Breath sounds heard.
CARDIOVASCULAR SYSTEM EXAMINATION
•Inspection : Bilaterally symmetrical chest present
No scars, sinuses
No visible pulsations
•Palpation:Inspectory findings are confirmed
Apex beat normal
• Auscultation : S1 S2 heard
No murmurs or additional heart sounds
PER ABDOMEN
Inspection:
Abdominal distension (Abdominal grith - 88.5cms)
No scars, sinuses, mass visible
Slit like umbilicus
•Palpation:
Inspectory findings are confirmed
No local rise of temperature
Tenderness present.
Fluid thrill absent
•Percussion:Shifting dullness present.
•Auscultation: Normal bowel sounds hear
No bruit heard
CENTRAL NERVOUS SYSTEM EXAMINATION
Higher mental functions intact
Cranial nerves intact
No focal neurological defecits
INVESTIGATIONS
4/8/22
8/8/22
DIAGNOSIS
Spontaneous Bacterial Peritonitis
Comments
Post a Comment