General medicine case 08

 General medicine case 08

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.

A 60 year old male, who work as goat breeder came to the OPD with the Cheif complaints of distended abdomen since 20 to 30 days,  abdomen pain since 1 week, decreased urine output since 2 days and constipation since 2 days.

History of Present illness:-

Patient was apparently asymptomatic since 1 month ago. Then he developed abdominal distension since 20-30 days which is progressive in nature and is associated with pain since 1 week with decreased urine output and constipation since 2days. 

Routine:- He wakes up at 5 A.M and have his food by 8 A.M and goes to work by 9 A.M. He will have lunch by 2 P.M. He returns to home by 7 P.M . And have his dinner by 9P.M and sleep by 10 P.M.

Past History:- 

No history of Hypertension and Diabetes.

No history of Asthma , Tuberculosis, Epilepsy.

No history of any previous surgery.

Personal History:- 

Patient takes mixed diet.

Sleep is abnormal.

Appetite is normal.

Bowel movements are regular.

Bladder movements are irregular.

Alcohol addiction he drinks occasionally.

Gutka chewer since 7 months.

Family History:-

No members in family has similar complaints.

Treatment History:-

Patient is not allergic to known drug.

General Examination:- 

Patient was coherent , consciousness and alert.

No anemia, pallor , cyanosis, icterus, clubbing of fingers.

No generalised lymphadenopathy.

Vitals:- 

Temperature :- afebrile.                                             Respiratory rate:- 16 cycles per min.                      Blood pressure:- 120/ 80 mm Hg.                           Pulse rate:- 100 bpm

Systemic Examination:- 

Abdominal examination:- shape distended.                                                     tenderness present.                                                   No palpable mass.                                                     No bruit.                                                                      Free fluid present.                              Liver and spleen are not palpable.                          Bowel sounds present.

CVS:-  S1S2 ,  NO MURMURS

Respiratory system --- No Dyspnoea.                                                             No wheezing sound.                                         Position of trachea is central

CNS----Patient is conscious.                                                   Speech is normal.                                                      Reflexes are normal 

Investigations:- 

Provisional diagnosis:-

HEMORRHAGIC ASCITIS SECONDARY TO PANCREATITIS..??