Case history -8
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A 28 year old female has come to casualty with chief complaints of abdominal distention since 5 days.
HISTORY OF PAST ILLNESS:
Patient was diagnosed with polyuria and type 2 diabetes 6 months and was given a medication.
Patient had pregnancy 5 months back and Inj.human insulin mixtard was given and she had a abortion at 2 months of gestation.
She had pain and stiffness in the metacarpal joint and proximal interpharngeal joint which was increased after the doing the household work.
She was detected to be antinuclear antibody (autoimmunity) in another hospital.
She had been on medication since she was on anticardiolipin postive which she used for a month and then stopped using it.
PERSONAL HISTORY:
Diet: mixed.
Appitite: lost .
Bowel and bladder movement:normal.
Micturition: normal
Addictions : no addictions.
Maternal status: married and had a and abortion .
FAMILY HISTORY:
No adequate family history.
TREATMENT HISTORY:
Had medication for type 2diabeties , anticardiolipin .
Patient had undergone a blood transfusion 8 months back.
GENERAL EXAMINATION:
Pateint concern was taken and examined in well lit room.
No pallor, cyanosis, icterus, clubbing, pedal oedema.
No generalised lymphadenopathy.
Patient had mild dehydration.
VITALS:
Temperature: afibrile
Respiratory rate:18/minutes.
Pulse rate:84beats / minutes.
Blood pressure:90/80mmHg.
SpO2:99%.
SYSTEMIC EXAMINATION:
Cardiovascular system:
No thrills and cardiac mummurs .
S1 and S2 are heard .
Respiratory system:
No wheezing and dyspnoea.
Positioning of trachea is central and breath sounds are vesicular.
Abdomen:
Shape of abdomen: distention.
No tenderness and no palpable mass is present.
No free fluid and bruits and liver and spleen are not palpable .
bowel sounds are heard .
Central nervous system:
Patient is conscious and speech is normal.No signs of meningeal irritation such as neck stiffness and kerning's sign.
Cerebral signs such as finger - nose in coordination and knee - heal incoordination are not present .
INVESTIGATIONS:
Serum electrolytes: sodium, potassium, chloride.
Blood sugar- fasting.
T3,T4,TSH:
Colour Doppler 2D Echo
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