77 year old male with abdominal distension
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box"
77 year old male daily wage laborer by occupation resident of narayanapuram came to opd with chief complaints of
-abdominal distension since 3 days
History of presenting illness:-
Patient was apparently a symptomatic until 3 days ago then he had complaints of sudden onset of abdominal distention accompined with twisting type of pain; Dyspnea, constipation decreased urine output, painful defecation aggravated after having food
No complaints of fever headache giddiness
No complaints of bilateral pedal edema
No complaints of burning micturition
Past illness:-
History of analgesic abuse for knee pain
History of empyema 15years ago
PERSONAL HISTORY: -
Diet - mixed
Appetite- normal
Sleep - normal
Bowel - regular
Bladder - decreased output and burning micturition
Allergies- none
Addictions- Beedi 4/ day
Toddy/ every 3 days
FAMILY HISTORY:Not significant
GENERAL EXAMINATION:
Patient is conscious, coherent and co-operative.
Examined in a well lit room.
Moderately built and nourished
Vitals
Temperature:-afebrile
Respiratory rate:- 16cpm
Pulse rate :-74bpm
BP:- 120/80mm Hg
Systemic examination
Cardiovascular system :-
INSPECTION:
Chest wall - bilaterally symmetrical
No dilated veins, scars, sinuses
Apical impulse and pulsations cannot be appreciated
PALPATION:
Apical impulse is felt on the left 5th intercoastal space 2cm away from the midline.
No parasternal heave, thrills felt.
PERCUSSION:
Right and left heart borders percussed.
AUSCULTATION:
S1 and S2 heard , no added thrills and murmurs heard.
Respiratory system
INSPECTION:
Chest is bilaterally symmetrical
Trachea – midline in position.
Apical Impulse is not appreciated
Chest is moving normally with respiration.
No dilated veins, scars, sinuses.
PALPATION:
Trachea – midline in position.
Apical impulse is felt on the left 5th intercoastal space.
Chest is moving equally on respiration on both sides
Tactile Vocal fremitus - appreciated
PERCUSSION:
The following areas were percussed on either sides-
Supraclavicular
Infraclavicular
Mammary
Axillary
Infraaxillary
Suprascapular
Infrascapular
Upper/mid/lower interscapular were all RESONANT.
AUSCULTATION:
Normal vesicular breath sounds heard
No adventitious sounds heard
Abdominal examination:-
Inspection:-
Shape of abdomen:-distended
Umblicus:- normal
Movements of abdominal wall :- moves with respiration
Skin is smooth and shiny
No scars sinuses
distended veins :- present
Palpation:-
Local rise of temperature present
Tenderness present in RT hypochondriac region
Tense abdomen
Guarding absent
Rigidity absent
Fluid thrill absent
Liver not felt
Spleen not felt
Kidney not felt
Lymph nodes not palpable
Percussion:-
Liverspan :- not detectable
Fluid thrill:-not felt
Shifting dullness:- present
Tympanic note is heard on midline and dull note is heard on flanks in supine position
Auscultation:-
Bowel sounds are decreased
CNS examination:- No neurological deficits seen
Provisional diagnosis :-
Ascites under evaluation
Investigations:-
Serology:-
Hiv-negative
Hcv- negative
HBsAg- negative
Outside USG:-
1. Liver altered parenchymal ecotextur
2. Cholecystitis
3. Bilateral grade 2 rpd changes with renal cortical cysts
4. Moderate ascites
Treatment :-
1.Iv fluids Ns@50ml/hr
2.T dolo650mg/po/tid
3.therapeutic ascitic tap was done
Comments
Post a Comment