35 Y/ F WITH ? ABDOMINAL TB

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  





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  




25/11/21 

Ward case 

35 Y/F with ? abdominal TB 


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 

Tab nitrofurantoin 100mg po/bd  

26/11/21 
Ward case 

35 Y/F with ? abdominal TB 


S: Fever spike + 
Abdomen distended tense , everted  umbilicus 
Increased abdominal girth and weight

    
O : Pt is conscious ,coherent, cooperative 

O/E 

PR 88 bpm
BP 90/60 mmHg 
RR 18 cpm
Temp 99 F 
GRBS 107 mg/dl

CVS : 

S1 S2 heard , no murmurs 

RS : 
NVBS + 
BAE + 

P/A : 
Abdominal girth - 77 cm 
Bowel sounds + 
No engorged veins 
Fluid thrill + 
Shifting dullness absent 
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 NITROFURANTOIN 100MG PO/BD  


 


27/11/21

Ward case 

35 Y/F with ?  abdominal TB 


S:  Fever spike + 
Night and today mrng 
    
O : Pt is conscious ,coherent, cooperative 

O/E 

PR 116 bpm
BP 80/50 mmHg 
RR 18 cpm
Temp 100.6   F 


CVS : 

S1 S2 heard , no murmurs 

RS : 
NVBS + 
BAE + 

P/A : 
Soft 
Abdominal girth - 73 cm 
Bowel sounds + 
No engorged veins 
Fluid thrill + 
Shifting dullness present 
No organomegaly 

Wt : 31 kgs 
Abd girth : 73  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 Egg white / day 
Tab NITROFURANTINE 100 MG /PO/BD 
ATT STARTED 

PLAN FOR DISCHARGE 

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