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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