35 Y/ F with ? Abdominal TB
A 35 yr old female , home maker with 2 kids
came to OPD with c/o
Loss of appetite since 1 month.
Abdominal distension since 15 days
SOB since 10 days
Pt was apparently asymptomatic 1 month back, patient had significant loss of appetite , then developed fever which is insidious in onset , gradually progressive , a/w chills and rigors , subsided on taking medication .
C/o abdominal distension since 15 days
SOB grade ll - lll
Not a/w orthopnea / PND
C/o loss of appetite
No c/o chest pain , palpitations , orthopnea , PND , cough ,cold
Not a k/c/o DM , HTN , TB, asthma , thyroid
H/o blood transfusion during her 2 nd pregnancy
O/E :
Patient is conscious , coherent , cooperative
BP 80/60 mmHg
PR 112 bpm
RR 20 cpm
Spo2 99% at RA
Grbs 115 mg/dl
Temp 101 F
CVS :
S1 S2 heard , no murmurs
RS :
VBS +
BAE +
P/A :
Abdominal girth - 74 cm
Bowel sounds +
No engorged veins
Fluid thrill +
Shifting dullness absent
No organomegaly
CNS : NAD ,HMF INTACT
Clinical images :
Provisional diagnosis :
Low SAAG ? Peritoneal tuberculosis
Investigations :
On 22/11/21
On 23/11/21
APTT 40 sec
PT 21 sec
INR 1.5
No pus cells
Polymicrobial flora grown
SPUTUM AFB :
No acid fast bacilli
Treatment :
Salt restriction less than 2.4 g/day
Fuild restriction
Tab ALDACTONE 50 MG /PO/OD
INJ NEOMOL 1 GM /IV ...IF TEMP MORE THAN 101 F
2 TSP BF PROTEIN POWDER IN 100 ML MMILK PO/TID
SOAP NOTES :
DAY 1
24/11/21
FEVER CHART :
S: Fever spike +
O : Pt is conscious ,coherent, cooperative
O/E
PR 104 bpm
BP 100/70 mmHg
RR 18 cpm
Temp 99 5 F
GRBS 124 mg/dl
CVS :
S1 S2 heard , no murmurs
RS :
NVBS +
BAE +
P/A :
Abdominal girth - 79 cm
Bowel sounds +
No engorged veins
Fluid thrill +
Shifting dullness absent
No organomegaly
Wt : 35 kgs
CNS : NAD ,HMF INTACT
A : ? Abdominal TB
P :
Salt restriction less than 2.4 g/day
Fuild restriction less than 1 lit/ day
Tab ALDACTONE 50 MG /PO/OD
INJ NEOMOL 1 GM /IV ...IF TEMP MORE THAN 101 F
Tab LASIX 40 MG /PO/OD
TAB PCM 650 MG /PO/OD
2 TSP BF PROTEIN POWDER IN 100 ML MMILK PO/TID
2 Egg white / day
Tab OROFER XT /PO/OD
Day 2
25/11/21
S: Fever spike +
O : Pt is conscious ,coherent, cooperative
O/E
PR 88 bpm
BP 100/70 mmHg
RR 18 cpm
Temp 99 F
GRBS 124 mg/dl
CVS :
S1 S2 heard , no murmurs
RS :
NVBS +
BAE +
P/A :
Abdominal girth - 71 cm
Bowel sounds +
No Engorged veins
Fluid thrill +
Shifting dullness absent
No organomegaly
Wt : 30 kgs
Abd girth : 71 cms
CNS : NAD ,HMF INTACT
A : ? Abdominal TB
P :
Salt restriction less than 2.4 g/day
Fuild restriction less than 1 lit/ day
Tab ALDACTONE 50 MG /PO/OD
INJ NEOMOL 1 GM /IV ...IF TEMP MORE THAN 101 F
Tab LASIX 40 MG /PO/OD
TAB PCM 650 MG /PO/OD
2 TSP BF PROTEIN POWDER IN 100 ML MMILK PO/TID
2 Egg white / day
Tab OROFER XT /PO/OD
SOAP notes
Day 3
26/11/21
S: Fever spike +
O : Pt is conscious ,coherent, cooperative
O/E
PR 90 bpm
BP 80/50 mmHg
RR 18 cpm
Temp 98.6 F
GRBS 107 mg/dl
CVS :
S1 S2 heard , no murmurs
RS :
NVBS +
BAE +
P/A :
Tense , distended
Abdominal girth - 77 cm
Bowel sounds +
No engorged veins
Fluid thrill +
Shifting dullness present
No organomegaly
Wt : 32 kgs
Abd girth : 77 cms
CNS : NAD ,HMF INTACT
A : ? Abdominal TB
P :
Salt restriction less than 2.4 g/day
Fuild restriction less than 1 lit/ day
Tab ALDACTONE 50 MG /PO/OD
INJ NEOMOL 1 GM /IV ...IF TEMP MORE THAN 101 F
Tab LASIX 40 MG /PO/OD
TAB PCM 650 MG /PO/OD
2 TSP BF PROTEIN POWDER IN 100 ML MMILK PO/TID
2 Egg white / day
Tab OROFER XT /PO/OD
Tab NITROFURANTINE 100 MG /PO/BD
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