A 44 yr old female came with C/O abdominal distension since 5 months
Pedal edema since 15 days
Patient is a telugu teacher by occupation and her routine includes - Wakeup at 6 AM and then cooking, washing dishes, having breakfast at 8 AM
At 8:30 AM, she will go to school, teaching till 1PM then lunch and again teaching till 4 PM.
Again at evening , back to home and then cooking, washing dishes, clothes, dinner at 8PM and to sleep at 10:00 PM
Birth History : Term, Normal vaginal delivery, Normal weight at birth. Attained all milestones acc. to age
At 16 yrs of age, she noticed ? group of vesicles over Right cheek (? Herpes Zoster) for which she used medication and got relieved.
She got married at the age of 20yrs
Obstetric history :
Conceived spontaneously after 5 years of marriage
First Pregnancy - abortion, spontaneously @ 3months
Then she was diagnosed with hypothyroidism on medication 50mcg
6 months later, Second Pregnancy - abortion spontaneously @ 3 months
6 months later, Third pregnancy - abortion spontaneously @ 3 months
1 year later, 4th pregnancy - delivered at 8th month, preterm baby with wt. of 1.5 kg ( At the age of 1 year, baby died due to dengue )
Past History:
In 2017, patient had c/o pain in MCP, PIP joints sparing thumb and DIP joints. Knee joint pain +
No involvement of Ankle, Elbow and shoulder joints
Pain relieved on medication ( wysolone 5 mg/ tadalafil 20mg/ HCQ 200mg ) . Then she was diagnosed with mixed connective tissue disorder
At the same time, she had c/o SOB, diagnosed with PAH, continued same medication (on &off due to affordable issues )
Inbetween 2018 - 2020, she used to have intermittent complaints of SOB, where it reduced by taking tadalafill 20mg stat
In 2020, due to covid pandemic she stopped visiting hospital and continued to take all medications (irregularly)
In Dec 2020, she went to another centre with c/o SOB and since then she is on medication irregularly until Jan 2022.
In Jan 2022, patient had c/o abdominal distension, decreased appetite, abdominal tightness even after consumption of little amount of food. Constipation +. No H/o fever, cold, cough, jaundice, pedal edema.
She then went to local hospital and not relieved on medication.
In march 2022, Advised for ascitic tap which was done 4 times (once for every 15 days) over the last 2 months
On 5th April 2022, ascitic fluid sent for investigation & Started ATT, used for 20 days (ADA -34.7) - No other ascitic fluid investigation reports are not available
After starting of ATT, C/o Giddiness, Generalised weakness, orange yellow coloured urine, SOB (grade II - III), Constipation +
On 2nd May 2022, ATT was stopped
Now on 12th May 2022, she came with c/o abdominal distension since 3 months, pedal edema (pitting type) since 15 days
C/o Blisters over right lower limb which were ruptured and healed on its own
No c/o Nausea, vomitings
No c/o Fever, cold, cough
No c/o loose stools
No c/o chest pain, palpitations, syncopal attacks
Stopped wysolone / HCQ / tadalafil 10 days back
No c/o Altered sleep patterns, Asterixis, Essential tremors, spider neavi
On examination :
BP - 130/70mmHg
PR - 79 bpm
RR - 16cpm
CVS - S1S2+
RS - BAE +
P/A - Distented , No organomegaly Abdominal striae +
B/L pitting edema +
Dermatology Referral done i/v/o blisters over right limb
Investigations :
Blood urea - 11 mg/dl
Ascitic fluid analysis : protein - 2.6 g/dl Sugar - 90 mg/dl Amylase - 27 IU/L LDH - 110 IU/L Ascitic albumin - 1.38 gm/dl SAAG - 0.98
HIV - Non Reactive HBsAg - Negative Anti HCV Antibodies - Non Reactive
Outside CT :
Provisional diagnosis -
Ascites under evaluation secondary to ? TB
H/o hypothyroidism
H/o severe PAH
Treatment -
1) Fluid Restriction < 1.5lt/ day
2) Salt Restriction < 2gm/ day
3) TAB LASIX 20mg PO/ BD
4) TAB ALDACTONE 50mg PO/ BD
5) SYP LACTULOSE 15ml PO/TID
6)ABD. Girth & Wt charting 12th hrly
SOAP NOTES
Day 2
14/05/22
S:
c/o burning sensation over right foot at blister region
SOB on exertion grade 2-3
No fever spikes
O:
Pt is c/c/c
Temp - 98°F
Bp - 110/80mmHg
PR - 81bpm
CVS - S1S2 +
RS - BAE+, B/L ISA crepts +
P/A - Distended, No Organomegaly
A:
Ascites under evaluation
secondary to ? TB
H/o hypothyroidism
H/o severe PAH
P:
plan for therapeutic ascitic tap around 1 lt
1)FLUID RESTRICTION <1.5L/day
2)SALT RESTRICTION <2gm/day
3)TAB LASIX 20mg PO/BD
4)TAB ALDACTONE 50mg PO/OD
5)TAB TADALAFIL 20mg PO/OD
6)TAB THYRONORM 75mcg PO/OD
7)SYP LACTULOSE 15ml PO/TID
8)FUDIC CREAM L/A BD
9)MUCOPAIN GEL L/A BD (20mins before food)
10)Abd. Girth & Wt Charting
SOAP NOTES
Day 3
15/05/22
S:
c/o abdominal distension
No fever spikes
O:
Pt is c/c/c
Temp - 98°F
Bp - 110/80mmHg
PR - 81bpm
CVS - S1S2 +, P2 reduced
RS - BAE+,
P/A - Soft, Distended, No Organomegaly
A:
Ascites under evaluation
secondary to ? TB
H/o hypothyroidism
H/o Severe PAH
P:
1)FLUID RESTRICTION <1.5L/day
2)SALT RESTRICTION <2gm/day
3)TAB LASIX 20mg PO/BD
4)TAB ALDACTONE 50mg PO/OD
5)TAB TADALAFIL 20mg PO/OD
6)TAB THYRONORM 75mcg PO/OD
7)SYP LACTULOSE 15ml PO/HS
8)FUDIC CREAM L/A BD
9)MUCOPAIN GEL L/A BD (20mins before food)
10)TAB PAN 40mg PO/OD
11)TAB ATARAX 25mg PO/OD
12)TAB TAXIM 200mg PO/BD
SOAP NOTES
Day 4
16/05/22
S:
c/o abdominal distension
No fever spikes
O:
Pt is c/c/c
Temp - 98°F
Bp - 100/80mmHg
PR - 78bpm
CVS - S1S2 +, P2 reduced
RS - BAE+,
P/A - Soft, Distended, No Organomegaly
CELL COUNT OF ASCITIC FLUID :
Appearance - clear
Colour - pale yellow
Total count - 45 cells/cumm
Neutrophils - 40%
Lymphocytes - 60%
RBC - Nil
Others - occasional mesothelial cells seen
Volume - 2ml
A:
Ascites under evaluation
secondary to ? TB
H/o hypothyroidism
H/o Severe PAH
P:
1)FLUID RESTRICTION <1.5L/day
2)SALT RESTRICTION <2gm/day
3)TAB LASIX 20mg PO/BD
4)TAB ALDACTONE 50mg PO/OD
5)TAB TADALAFIL 20mg PO/OD
6)TAB THYRONORM 75mcg PO/OD
7)SYP LACTULOSE 15ml PO/HS
8)FUDIC CREAM L/A BD
9)MUCOPAIN GEL L/A BD (20mins before food)
10)TAB PAN 40mg PO/OD
11)TAB ATARAX 25mg PO/OD
12)TAB TAXIM 200mg PO/BD
13)TAB MVT PO/OD
ESR - 30
C- reactive protein - Positive (1.2mg/dl)
Ascitic ADA - 33 U/L
SOAP NOTES Day 6 18/05/22
S:
c/o abdominal distension
No fever spikes
O:
Pt is c/c/c
Temp - 98°F
Bp - 110/80mmHg
PR - 78bpm
CVS - S1S2 +
RS - BAE+,
P/A - Soft, Distended, No Organomegaly
A:
Ascites under evaluation
secondary to ? TB
H/o hypothyroidism
H/o Severe PAH
P:
PLAN TO START ATT
1)FLUID RESTRICTION <1.5L/day
2)SALT RESTRICTION <2gm/day
3)TAB LASIX 20mg PO/BD
4)TAB ALDACTONE 50mg PO/OD
5)TAB TADALAFIL 20mg PO/OD
6)TAB THYRONORM 75mcg PO/OD
7)SYP LACTULOSE 15ml PO/HS
8)FUDIC CREAM L/A BD
9)MUCOPAIN GEL L/A BD (20mins before food)
10)TAB PAN 40mg PO/OD
11)TAB ATARAX 25MG PO/OD
12)TAB MVT PO/OD
