60 yr old with Abdominal distension since 3 months
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M.Abhignya
Roll No.83
Case:
A 60 year old male with Abdominal distension since 3 months
History of presenting illness:
Patient was apparently asymptomatic until 3 months ago He then he complained of abdominal discomfort which was Sudden gradually progressive accompained with Bloating Sensation and tightness;
SOB aggreviated after having food
History of similar complaints 3 months ago and ascitic tap was done.
c/o loss of appetite.
H/o Lower abdominal pain 5 months ago.
No Clo Decreased or Increased urine output, Burning Micturition
No c/o chest pain, orthopnea; PND; Sweating; Palpitations
No clo Cough, Cold.
No c/o loose stools,Constipation,Nausea,Vomitings
Past history
H/o Jaundice 2 years ago. used Herbal Medication.
Not a k/c/o DM,HTN,TB,Asthma,Epilepsy
Personal history:
Diet:mixed
Appetite: adequate
Bowel and bladder: regular
Addictions: patient was an occasional alcoholic from the age of 20 years and from the age of 40 he has been a regular alcoholic.
He drinks local sara but stopped 5 months back.
General examination: Patient is conscious,coherant and cooperative,moderately built and moderately nourished.
Pallor present
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No pedal edema
Vitals:
Temperature: afebrile
Pulse rate: 70 bpm
Blood pressure: 110/70 mm Hg
Respiratory rate: 18cpm
Systemic examination:
CNS: no focal neurological Deficits
CVS: S1 and S2 are heard
Respiratory: bilateral air entry is present
Abdomen: abdomen distended,soft and non tender. Shifting dullness present and bowel sounds are heard
Investigations:
Provisional diagnosis:
Chronic decompensated liver disease with portal hypertension
Ascites and spleenmegaly present
?Chronic hepatits B positive
?hepato renal syndrome
Treatment:
FLUID RESTRICTION 1.5L day
Salt restriction less than 2grams/day
TAB. ALDACTONE 50mg per oral OD
Tab lasix 20mg per oral BD
Protein powder 2 scoops in a glass of milk per oral BD
Daily abdominal girth monitoring
Vital monitoring
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