General medicine case 7

 Case : A 35 Year old woman with sleroderma, pedal edema and ascites

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A 35 year old female who is asha worker by occupation came to the opd with chief complaints of swelling of both legs since 6 days and abdominal distension since 6 days.

HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic 7 days back and she observed swelling in both legs bilaterally  which was insidious in onset and progressive .it has worsened  In the last three days .it is of putting type.A

Abdominal distension since 6 days , which has worsened since the last 2 days .

There has been a decreased urine output since two days 

There is a history of vomiting , 4-5 episodes daily since 1 day . The vomitus was non bilious and non projectile.

No history of loose stools 

HISTORY OF PASTILLES: 

Patient was dengue positive last month and was treated symptomatically. 

She is not a know case of daibetes , hypertension , and tuberculosis

No past surgical history .

PERSONAL HISTORY:

Diet : mixed 

Appetite : normal 

Sleep: adequate

Bowel and bladder : Regular till 2 days ago 

No allergies

No addictions

ON EXAMINATION: 

Patient is concious , coherent and cooperative.

Moderately built and moderately nourished .

 Pallor: absent 

Icterus : absent

 Clubbing : absent 

Cyanosis : absent 

Lymphadenopathy : absent 

Edema:  present and pitting type 

Vitals : 

Temperature- 98.6°f

Skin- streched , shiny skin is present on the face and over the shins 

Hypopigmented spots were seen bilaterally on the anterior aspect on the legs .

SYSTEMIC EXAMINATION : 

CVS- S1and S2 heard 

RS- BAE+ ,NVBS 

CNS- No focal deficit 

Lab Results:

Provisional Diagnosis:

Ascites under evaluation

Bilateral pleural effusion

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