66 year old Male with Abdominal distention
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Name - S.Kavya, 9th sem
Roll no - 121
I have been given this case to solve an attempt to understand the topic of "patient clinical analysis data " to develop my competency in reading and comprehending clinical data including clinical history,clinical findings, investigations and come up with a diagnosis and treatment plan
A 66 yr old male patient resident of jagatpally and toddy climber by occupation presented with the complaints of abdominal distention since 1 1/2 month
Nausea and decreased appetite since 1 1/2 month
Decreased urine output since 10 days
Constipation since 2 days
Patient was apparently asymptomatic 2 months back, then he noticed abdominal distention which was insidious in onset and gradually progressive in nature. No aggravating or relieving factors
Patient attenders noticed that he is reducing body weight
He complaints of decreased urine output since 10 days
Not passing stools since 2days passing flatus
History of fall from tree while climbing 5 years back
Past History
No h/o Diabetes, hypertension, Asthma, Tuberculosis , Epilepsy
Personal History
Appetite - decreased since 1 month
Diet - mixed diet
Bowel and bladder - constipation+
Sleep - adequate
Addictions - occasionally takes Alcohol
Family History
Insignificant
General Examination
Patient - conscious,coherent , cooperative
Moderately built, moderately nourished
Temperature 98.6
Pulse - 98bpm
Respiratory rate -16cycles per min
Blood pressure - 120/70mmHg
SpO2 - 98% at room air
Jvp normal
No pallor, icterus , cyanosis, clubbing, lymphadenopathy
Systemic Examination
Per abdomen examination
Abdomen distended
Umblicus - slit like
No engorged veins or No visible peristalisis
Local rise of temperature
Tenderness present diffuse over upper abdomen
Fluid thrill present
Bowel sounds +
Respiratory system
BAE+
CVS
S1 S2 heard
CNS
Higher mental functions intact
Ascitic tap - SAAG : 0.5
Sugars - 78
Proteins - 3.9
Diagnosis - Ascites due to ?? Tuberculosis? Malignancy ?
Treatment
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