A 60 YR OLD FEMALE WITH C/O ABDOMINAL TIGHTNESS


CHEIF COMPLAINTS:-
C/O ABDOMINAL DISTENSION SINCE 15 DAYS AND AND ABDOMINAL TIGHTNESS SINCE 15
DAYS
HOPI:-
Patient was apparently asymptomatic 10 years back.
Then she came to our hospital for a routine checkup as she was weak and diagnosed with
Hypothyroidism.She used medication for about 1 year then stopped as she was told that it has come
to normal.Again started using medication since 3 years as advised by doctor.
After 3 months again she came to our hospital as she had giddiness and was diagnosed with
Diabetes and Hypertensionfor which she used medication for about 1 year and stopped.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.
History of Chronic Cough not associated with sputum 1 month back and subsided by
inhalation(Ipratropium bromide)
Now since 15 days she had abdominal distension and tightness since for which she was frequently
visiting our hospital and she was told to admit on 4/8/2022
No history of pain, vomiting.
PAST HISTORY :-
K/C/O ASTHMA SINCE 5 YEARS ON INHALATION FORMETROL FUMARATE AND BUDESONIDE
INHALATION
K/C/O HYPOTHYROIDISM SINCE 10 YEARS ON MEDICATION THYRONORM 50 MCG
STOPPED IN THE MIDDLE AND STARTED 2 YEARS BACK
K/C/O HTN SINCE 10 YEARS ON MEDICATION METFORMIN 500 MG
K/C/O HYTPERTENSION SINCE10 YEARS ON MEDICATION TELMA-40 MG
NOT A K/C/O CVA/CAD/EPILEPSY/TB
PERSONAL HISTORY:
she is married housewife by occupation
APPETITE -NORMAL
NON VEGTARIAN
BOWEL -REGULAR
MICTRITION- NORMAL
NO KNOWN ALLERGIES
ADDICTION
NOT a ALCOHOLIC
CHEWABLE TOBACCO SINCE 20YEARS
NO H/O DURG INTAKE
NO H/O BETEL NUT INTAKE
NO H/O BETEL LEAF INTAKE
FAMILY HISTORY:
NO H/O DIABTES,HYPERTENSION,HEART
DISEASE,STROKE,CANCER,TUBERCULOSIS,ASTHMA,
PHYSICAL EXAMINATION:
WEIGHT -57KG
PALLOR-PRESENT
ICTERUS PRESENT
CYANOSIS ABSENT
CLUBBING OF FINGERS / TOES - ABSENT
LYMPHADENOPATHY- ABSENT
EDEMA OF THE FEET-ABSENT
TEMPPERATURE -99.5 F
PULSE RATE -102 BPM
BP-120/60MM HG
spo2 -98%
GRBS-170mg %
SYSTEMIC EXAMINATION
CVS EXAMINATION
no thrills
s1 and s2 -heard
NO CARDIAC MURMURS
RESPIRATORY SYSTEM EXAMINATION
NO DYSPNEA
NO WHEEZING
TRACHEA- CENTRAL
VESICULAR BREATH SOUNDS
RALES -1 RUB
ABDOMINAL EXAMINATION
SHAPE OF THE ABDOMEN - DISTENDED[ABDOMINAL GIRTH- 88.5 CMS ]
Inspection:
Abdominal distension
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 heard
No bruit heard
CNS EXAMINATION:-
HMF intact
Cranial nerves intact
No focal neurological defecits
BRIEF COURSE IN HOSPITAL :-
Pt came with complaints of abdominal distension and abdominal tightness , usg was done which
showed features of gross ascites and features suggestive of chronic liver disease . a diagnostic tap
was done and reports suggestuve of high saag low protein ascites and started on medication.
therapeutic tap was done for symptomatic releif
gastro opinion was taken i /v/o chronic liver disease and endoscopy was done showing grade 2
esopghageal varices
Investigation
USG:
IMPERSION:-
COARSE ECHOTTEXTURE WITH SURFACE IRREGULARITY OF LIVER S/O CHRONIC LIVER
DIEASE
-GROSS ASCITES
-C-REACTIVE PROTEIN -NEGATIVE
-ESR - 25
-SERUM LDH -459IU/L
-SPOTURINE
PROTIEN - 8
CREATINE -10.8
RATIO-0.74
SAAG - 2.17
ASCITIC:-
APPEARS-CLEAR
TLCOUNT- 550CELLS/CUMM
N-20
L-80
RBC -NIL
LDH-76[DECREASED]
SUGARS-143[INCREASED]
PROTEIN-1.0 [DECREASED]
CYTOLOGY:-V=2ML
COLOUR -PALE YELLOW
APPEARENCE- CLEAR
TL -200CELLS
PL -75% L;15%N
RBC -NIL
OTHERS -OCC.MESOTHELIAL CELL PRESENT
Diagnosis
CHRONIC LIVER DISEASE SECONDARY TO ?? NAFLD
K/C/O HTN , DM , HYPOTHYROIDISM
Case History and Clinical Findings
A 60yr old female Resident of Narketpally who is housewife came to the OPD with chief complaints of
Abdominal distension and tightness since 15 days
Treatment Given(Enter only Generic Name)
1.FLUID AND SALT RESTRICTION
2.TAB. NORFLOX 400 MG PO/OD
3.TAB .CARDIVAS 3.25 MG /PO/BD
4.TAB.RANTAC 150 MG/PO/BD
5.TAB.PCM 650 PO/SOS
6.TAB.METFORMIN 500MG PO/OD
7.TAB.TELMA 40MG/PO/OD
8.TAB.THYONORM 80 MG/PO/OD
9.TAB.ALDACTONE 150MG /PO/OD
10.TAB.LASIX 20MG /PO/BD
11.TAB.HEPKART 400MG/PO/OD
12.PROTEN-X-POWDER/SCOOP IN 100 MILK /PO/BD
13.SYP.LACTULOSE 20 ML/PO/TID
14.INJ.CEFOTAXIM 2MG/IV/BD
Advice at Discharge
1.FLUID AND SALT RESTRICTION
2.TAB. NORFLOX 400 MG PO/OD
3.TAB .CARDIVAS 3.25 MG /PO/BD
4.TAB.RANTAC 150 MG/PO/BD
5.TAB.PCM 650 PO/SOS
6.TAB.METFORMIN 500MG PO/OD
7.TAB.TELMA 40MG/PO/OD
8.TAB.THYONORM 80 MG/PO/OD
9.TAB.ALDACTONE 150MG /PO/OD
10.TAB.LASIX 20MG /PO/BD
11.TAB.HEPKART 400MG/PO/OD
12.PROTEN-X-POWDER/SCOOP IN 100 MILK /PO/BD
13.SYP.LACTULOSE 20 ML/PO/TID
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR
ATTEND EMERGENCY DEPARTMENT.





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