A 60 year old woman with high fever, distended abdomen, pedal edema

24 August, 
Hi, I am Nandini 3rd sem student. This is an online e logbook to discuss our patients health data shared after taking case of her guardians consent. This also reflects patient centred care and online learning portfolio.
 
CHEIF COMPLAINTS:
Fever since 15 days, pain in the abdomen since 2 days, distension of abdomen since 2 days. 

HOPI:  ( Presenting) 
Patient admitted on 12th of august with high fever and convulsions. Apparently, she developed pain in the abdomen since 2 days along with distension of abdome

HOPI: (Past) 
No significant past illness

Personal history:
She is married and a daily wage worker. 
Appetite
Bowel
Micturition
Addictions:  she is a regular consumer of alcohol since 15 years. 
Positive history of toddy intake and bettle nut intake. 
Family history:


PHYSICAL EXAMINATION:
General examination-
Pallor not seen
Icterus not seen
Cyanosis not seen
Clubbing not seen
Clubbing of fingers and toes- absent
Lymphadenopath- absent
Edema of feet is- present

Vitals:
Bp-
Pulse rate-90 beats per min
Respiratory rate-
Spo2-99
Temperature-99.1 degree fahrenheit

SYSTEMIC Examination:
. Cvs
No thrills
S1s2 heard
No cardiac murmurs

. Respiratory examination



.Abdominal examination

Shape of abdomen- obese
Palpable mass not seen

CNS -
She is conscious
Incoherent speech is seen
No neck stiffness
In Cranial nerves, motor system, sensory system no abnormal detected(NAD). 

Investigations:
ECG:


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