55 yr old female came to casualty with complaints of pedal edema since 6 days, which is insidious in onset and gradually progressive, worsening since 3 days.
- c/o abdominal distension since 6 days
- h/o decreased urine output since 2 days
- h/o vomiting s 4-5 episodes since 1 day
HOPI :pt was apparently asymptotic 1 week back, then he developed pedal edema ,which is bilateral ,pitting type it is worsening since 3 days
H/o burning micturition
H/o vomitings ,4-5 episodes which are non bilious,non projectile
No H/o loose stools
H/o fever in the last month, and that was diagnosed to be Dengue possitive and was treated symptomatically
Past history :
She is not a k/c/o DM, HTN , Asthma ,TB , epilepsy
On examination :
Pt is C/C/C
No pallor , icterus clubbing cyanosis lymphadenopathy, edema
Vitals :temp : 98.6f
CVS :S1S2 +
RS : BAE+ , NVBS
CNS - No focal deficits
Provisional diagnosis
Ascites under evaluation ,B/l pleural effusion
(SAAG 1.1),? systemic sclerosis:
Treatment
1)Fluid restriction< 2L /day
2)Salt restriction <2g/day
3)inj.zofer 4 mg IV.sos
4)Inj.Tramadol 1 amp in 100 ml NS/IV SoS
5)Tab.Dolo 650 mg po/sos
6)syp.potchlor 10 ml po /BD in a glass of water
7) abdominal girth monitoring
8)daily weight monitoring
9)vitals monitoring 6th hourly
10) Tab.Lasilactone 20/50 mg
11)Tab.ultracet 1 1/2-1/2-1/2-1/2(QID)
SOAP notes
Day 2
AMC bed 4
SOAP notes day 2
S:
Regurgitation of water 4-5 episodes
Not passing stools since 2 days
O:
Temp: afebrile
BP:90/50 mmHg
PR:92 bpm
CVS:S1,S2 heard
RS: BAE +
P/A :distended, shifting dullness present,bowel sounds heard
Abdominal girth:89 cms
Weight:60 kgs
I/O :950/780
CNS:NAD
A: Ascites under evaluation,b/l pleural effusion (L>R)
P:
1)Fluid restriction< 2L /day
2)Salt restriction <2g/day
3)inj.zofer 4 mg IV.sos
4)Inj.Tramadol 1 amp in 100 ml NS/IV SoS
5)Tab.Dolo 650 mg po/sos
6)syp.potchlor 10 ml po /BD in a glass of water
7) abdominal girth monitoring
8)daily weight monitoring
9)vitals monitoring 6th hourly
10) Tab.Lasilactone 20/50 mg
11)Tab.ultracet 1 1/2-1/2-1/2-1/2(QID)
Day 3 SOAP notes
AMC bed 4
SOAP notes day 2,(35/F)
S:
Regurgitation of water 4-5 episodes
Not passing stools since 2 days
O:
Temp: afebrile
BP:90/50 mmHg
PR:92 bpm
CVS:S1,S2 heard
RS: BAE +
P/A :distended, shifting dullness present,bowel sounds heard
Abdominal girth:89 cms
Weight:60 kgs
I/O :950/780
CNS:NAD
A: Ascites under evaluation,b/l pleural effusion (L>R)
SAAG 1.1
P:
1)Fluid restriction< 2L /day
2)Salt restriction <2g/day
3)inj.zofer 4 mg IV.sos
4)Inj.Tramadol 1 amp in 100 ml NS/IV SoS
5)Tab.Dolo 650 mg po/sos
6)syp.potchlor 10 ml po /BD in a glass of water
7) abdominal girth monitoring
8)daily weight monitoring
9)vitals monitoring 6th hourly
10) Tab.Lasilactone 20/50 mg
11)Tab.ultracet 1 1/2-1/2-1/2-1/2(QID)
A
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