65 yrs old male with abdominal distension
Patient particulars
Age 65yrs
Gender Male
Address Pochampally
Occupation Shepherd
Date of admission 5/11/2021
Date of examination 6/11/2021
Chief/presenting complaints:
Pain abdomen since 1 month
Distention of abdomen since 1 month
History of presenting complaints/illness :
Pain abdomen:
Distention of abdomen:
Onset- insidious
Duration -1 month
Progression -gradual
No Aggravating factor&Reliving factors
Associated pain abdomen
No Yellowish Discolouration of skin and eyes
No Mass palpable per abdomen
Past history:
No Similar complaints in the past.
No h/o Hypertension ,Diabetes ,malignancy,epilepsy ,TB and other chronic
illness in the past
Deaf and dumb by birth
Past surgeries and medical interventions in the past.
Family history
No Similar complaints in the family.
No h/o Hypertension
,Diabetes ,malignancy,epilepsy ,TB and other chronic
illness in the family
Personal history :
Diet Mixed
Appetite decreased
Sleep Adequate
Bowel and bladder habits Regular
No Substance abuse
Drug/Treatment history:
Frequent use of pain killers for pain since 10 days
General physical examination:
Patient is conscious & well oriented to Time place and person.
Lean Built
Moderately Nourished
Vitals:
Pulse 80
Blood pressure.: 110\70 mm Hg
Respiration. 16cpm
Temperature. Afebrile
No Pallor Icterus Cyanosis Clubbing Edema Lymphadenopathy
Signs of liver failure:
No Alopecia / Icterus / Parotid Gland Enlargement / Spider naevi /
Gynaecomastia / Ascites / Testicular atrophy / Palmar Erythema /
White Nails / Clubbing / Flapping Tremors / Dupytrens Contracture
External markers of HIV infection :
No Oral Hairy Leukoplakia / Oral Candidiasis / Moluscum contagiosum /
Generalised lymphadenopathy / Recurrent Herpetic Infections
Systemic Examination
Abdomen examination.
Oral Cavity-Good Hygiene
Inspection:
Uniformly Distended
Umbilicus-slit like / Everted
Flanks full
No Sinus /scar/dilated veins
No visible Hernial orifices
No Visible peristalsis
No Visible lump
Palpation
All the inspectory findings are confirmed
Local rise of temperature
Tenderness present
No Guarding/rigidity
No Palpable lump
No Organomegaly on Palpation of spleen ,liver,Kidney.
Percussion :
Liver Dullness present from 5th Intercostal space
Fluid Thrill present
Auscultation :
Bowel sounds - Small bowel-3-5/min
Other systems:
Cardiovascular system S1 S2 HEARD, NO MURMERS
Respiratory system NORMAL VESCULAR BREATH SOUNDS OVER THE LUNG FIELDS
Summary
A 65 yrs old male came with chief complaints of abdominal distension for 1 month under evaluation
Provisional diagnosis
Ascites for evaluation
Differential diagnosis.
Cirrhosis of liver
Management: Investigation and Treatment.
Ascitic tap
Ultrasound Abdomen
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