Kiran, a 60-year-old male, presented with abdominal distension and no urine output for 2 days. Examination found ascites and pleural effusion. Lab results showed elevated creatinine, ESR, and blood sugars indicating diabetes and hypertension. The patient has a history of hypothyroidism, diabetes, and hypertension. Ultrasound revealed free fluid in the abdomen consistent with a diagnosis of ascites, likely due to cirrhosis given the patient's history of alcohol use and liver disease risk factors. The patient was counseled on lifestyle changes including limiting alcohol, losing weight, exercising, and reducing salt intake.

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

8. US- ABDOMIN ;

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.

11. PATHOPHYSIOLOGY :

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