66 YEAR OLD MALE WITH ABDOMINAL DISTENSION

Medicine case discussion

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 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 in the comment box are welcome.


Name - K Pranati 9th sem

Roll no - 168



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












9 Nov 2021











Ascitic fluid cytology

Neutrophils 60%
Lymphocytes 40%









CBNAAT - Negative






Mantoux test







Xray abdomen







CT Abdomen
























Diagnosis - Ascites due to ?? Tuberculosis? Malignancy ?

Treatment 

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