A 65 yr old female with ascites

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 A 65 year old female, resident of suryapet , who used to be a farmer by occupation was presented to the opd with chief complaints of

CHIEF COMPLAINTS:

• Fever since 15 days
• SOB since 15 days
• Decreased urine output since 15 days

HISTORY OF PRESENTING ILLNESS

the patient was apparently asymptomatic 20 days ago when she developed fever and decreased urine output for whivh she visited a local hospital and was on medication. The fever subsided.4 days later her urine output decreased and gradually developed abdominal distension over a period of 5 days. For this she went to a hospital where she was told that she has a kidney problem? Her creatinine levels were high and foleys catheter was inserted. Her symptoms were relived and She was discharged. But then later she came to our opd with complaints of SOB and abdominal distension 

HISTORY OF PAST ILLNESS 

H/o DM and HTN since 3 years

No similar complaints in past

PERSONAL HISTORY 

chronic alcoholic since 30 years

Chronic smoker since 30 years

Diet mixed

Sleep adequate 

FAMILY HISTORY 

no significant family history 

EXAMINATION:

General examination:

The patient is conscious coherent and co operative

Moderately built and nourished

No pallor

No cyanosis 

No clubbing 

No lymphadenopathy 

Mild bilateral pedal oedema

SYSTEMIC EXAMINATION 

CVS 

S1 S2 heard

No murmers

RESPIRATORY 

Dyspnoea

No wheeze

Breath sounds vesicular 

Trachea central

Bilateral BAE +

ABDOMEN 

Free fluid present

Soft and non tender

Spleen and liver non palpable

No palpable mass 

CNS

conscious coherent

Speech nornal

Motor system normal

Sensory system normal

Reflexes normal

PROVISIONAL DIAGNOSIS 

Bacterial peritonitis

With AKI

INVESTIGATIONS 

USG abdomen impression: gross ascites 

TREATMENT 

18/06/2022

IVF 1UNIT NORMAL SALINE @30ML/HOUR

INJ LASIX 20MG IV TWICE DAILY 

TAB ALDACTONE 25 MG ORALLY ONCE DAILY 

PROTEIN POWDER 2 SCOOPS IN GLASS OF MILK PER ORALLY THRICE DAILY 

INJ MONOCEF 1GM IV TWICE DAILY 

INJ PAN 40MG IV ONCE DAILY BEFORE BREAKFAST 

INJ ZOFER 4MG IV SOS

INJ HAI S/C THRICE DAILY 

19/06/2022

IVF 1UNIT NORMAL SALINE @30ML/HOUR

INJ PAN 40MG IV ONCE DAILY BEFORE BREAKFAST 

INJ ZOFER 4MG IV SOS

TAB LASIX 20MG ORALLY TWICE DAILY 

TAB TAXIM 1GM IV TWICE DAILY 

20/06/2022

INJ CEFTRIAXONE 2MG IV THRICE DAILY 

INJ RANTAC 50MG IV ONCE DAILY 

INJ LASIX 20MG IV TWICE DAILY 

INJ TRAMADOL 2 AMPULES SOS 

IVF I UNIT NORMAL SALINE @30ML/HOUR

21/06/2022

INJ CEFTRIAXONE 2MG IV THRICE DAILY 

INJ RANTAC 50MG IV ONCE DAILY 

INJ LASIX 20MG IV TWICE DAILY 

INJ TRAMADOL 2 AMPULES SOS 

IVF I UNIT NORMAL SALINE @30ML/HOUR

22/06/2022

INJ CEFTRIAXONE 2MG IV THRICE DAILY 

INJ RANTAC 50MG IV ONCE DAILY 

INJ LASIX 20MG IV TWICE DAILY 

INJ TRAMADOL 2 AMPULES SOS 

IVF I UNIT NORMAL SALINE @30ML/HOUR

TAB  ALDACTONE 50mg OD

The patient passed away on 24/6/22 3:03 am due to acute pulmonary thromboembolism . Antecedent cause being ascites secondary to SBP.