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Ascites for medicine residents and doctors
- 2. PATIENT DETAILS: Patient Name: Kiran Age: 60yrs Sex: male IP No: 2511 DOA: 2/11/22 DOD:10/11/22 Department: GMW CHIEF COMPLAINTS: • Abdominal distention • No urine output for 2 days
- 3. ON EXAMINATION Temp: 98.6 Pulse Rate: 85 b/m SPO2 : 96% BP : 120/90 mmHg Social History : Diet : Non veg Alcohol : Yes , since from 10yrs
- 4. PAST MEDICAL HISTORY Hypothyroidism Diabetes Hypertension
- 5. PAST MEDICATION HISTORY Levothyroxine : 25mcg Irregular drug use for diabetes Amlodipine : 5mg
- 6. LABORATORY INVESTIGATIONS Parameters Observed Values Normal Values Units Hemoglobin 9 14- 16 g/dl ESR 80 1- 7 mm/hr Platelet Count 2,00,000 1,50,000- 4,00,000 Cells/cumm RBC 2.8 3.8-5.8 Millions/cumm Neutrophils 80 40-75 % Lymphocytes 10 20- 45 % Serum Creatinine 1.8 0.6-1.2 mg/dl
- 7. LABORATIRY INVESTIGATIONS Parameters Observed Value Normal Value Units Na+ 133 134-155 mEq/l Chlorides 81 98-107 mEq/l Fasting Blood Sugar 130 70-110 mg/dl Random Blood Sugar 266 110-180 mg/dl TSH 0.38 0.35-4.0 mlu/ml FT4 1.0 0.8-1.8 ng/dl FT3 3.5 2.3-4.2 pg/dl
- 9. IMPRESSION ; Moderate free fluid seen in the abdomin. Bilateral moderate pleural effusion. DIAGNOSIS : ASCITES
- 10. DEFINITION : Ascites is defined as the accumulation of free fluid in the peritonial Cavity. ETIOLOGY : It can be caused due to the liver problems like cirrhosis, acute liver failure, others like heart failure, nephrotic syndrome, disorders of pancreas.
- 12. PRESENT MEDICATION HISTORY : s.no Brand Name Generic Name R.O.A Dose Frequenc y 1. Uribid Nitrofurant oin po 100mg OD 2. Thyronor m Levothyro xine po 25mcg OD 3. Ursocol Ursodeox ycholic po 300mg OD 4. Glyset Miglitol po 25mg BD 5. Norvasc Amlodipin e po 5mg 0D 6. Pantop Pantapraz ole po 40mg 0D 7. Benfoplus Folicacid ….. …….. BD 8. Aldactone spironolac tone po 100mg BD
- 13. SOAP NOTES : Subjective – Abdominal distension, no urine output for 2days. Objective – Hb ; 9gm ESR ; 80mm/hr RBC; 2.8 Neutrophils; 80 Lymphocytes; 10 Na+; 133 Serum creatinine; 1.8 Cl-; 81 FBS; 130 RBS; 266
- 14. ASSESMENT ASCITES PATIENT COUNSELLING : Limit alcohol intake. Weight loss Exercising Limit salt intake Once it is arrived, to check that not to be prone.
- 15. PRESENTED BY: M. DURGA ROHITHA PHARM-D IV YEAR 174T1T0005