A 47 year old female with ascites and pedal edema.

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Chief complaints: SOB since 1 week, itching and abdominal distension since 1 week and lower lumbar pain ( sacral tenderness). 

History of present illness :  

She is a known case of Extrapulmonary TB( she found a lump in the right supraclavicular fossa for which biopsy was suggested and TB was confirmed) with Ascites on ATT 21/07/2022; Now presented to the OPD with complaints of Generalized Itching 7- 10 days after starting the ATT regimen. History of shortness of breath not associated with Orthopnea and PND since 10 days. There was also history of pedal edema( pitting type) of both the lower limbs.History of gradual painless abdominal distention associated with lower back pain since a week. No history of chest pain, palpitations, bleeding manifestations, fever and cough.

History of past illness:

Diagnosed as a diabetic 6 years ago (she went for a normal check up for generalized weakness). In the month of march this year,she developed pedal edema and routine check up confirmed that she has Hypertension and hypothyroidism, was treated and managed appropriately. 

After a month of discharge she had complaints of painless gradual abdominal distention and grade II NYHA SOB, she sought for consultation and admitted. Therapeutic and Diagnostic ascitic tap was done under aseptic condition and reports were found to be Low SAAG Low protein. Ascitic fluid was removed 3 times untill now. 

Family history : 

not significant.

Surgical history : 

tubectomized under LA (20 years ago) 

PERSONAL HISTORY:

A 47 year married female, home maker.

Normal Appetite

Decreased food intake because of SOB d/t abdominal distention.

Irregular Bowel - hard stools.

Decreased Micturition.

No addictions.

GENERAL EXAMINATION:

Patient was conscious and coherent.

Afebrile.

Pallor +;

 clubbing+;

 lymphadenopathy+; 

pedal edema +; 

cyanosis -; 

Icterus -.

Vitals :

BP: 160/110.

Temperature: afebrile. 

Pulse rate :92bpm

RR: 21.

Grbs:88mg/dl.

Per abdomen : distended, flankfullness present, fluid thrill seen and shifting dullness present. 

No distended veins Or scars seen. Normal skin texture. 

Systemic examination

Respiratory examination:

BAE +,NVBS, no crackles and no wheezing. 

CVS:

S1, S2 heard. Apex beat prominently  heard below the left nipple. 

CNS examination

 Patient is conscious and coherent.HMF +, GCS 15/15.

Investigations

Chest X ray:

2D echo:

TREATMENT:

1. TAB. LASIX 40MG/PO/BD.

2. TAB. TELMA 40 MG/PO/OD.

3. TAB. METOLAZONE 10MG/PO/BD.

4. TAB. OROFER XT /PO/OD.

5. TAB. THYRONORM 100mcg/PO/OD.

6. CAP. BIO D3/PO/ONCE WEEKLY.

7. INJ. HUMAN ACTRAPID INSULIN/ ACCORDING TO GRBS/TID.

8. TAB. RIFAMPICIN 450MG

9. TAB. ISONIAZID 225MG

10. TAB. PYRAZINAMIDE 1200MG

11. TAB. ETHAMBUTOL 825MG

12. GRBS MONITORING.

13. VITAL AND TEMP CHARTING 4TH HOURLY.