56 year old patient with pain in the abdomen.

56 yr old Male patient with pain in abdomen



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A 56 year old man came to OPD with the chief complaint of pain in abdomen, abdominal distension and decreased urine output since 4 days.

HOPI-

Patient was apparently asymptomatic 4 days back,then he developed pain in abdomen (upper abdominal region).He complained of distension of abdomen since 4 days.

No history of nausea, vomitings and constipation.last alcohol consumption 5 days back.



HISTORY of Past Illness 
Patient is alcoholic 
Patient has wrist pain since 2 years.
Not a known case of diabetes mellitus, hypertension and CAD.



PERSONAL HISTORY
Diet: mixed 
Appetite:normal 
Bowel movements: normal 
Addictions: alcohol

 Family history;- 
No similar past family history 

GENERAL EXAMINATION
Patient is conscious, coherent, cooperative, well oriented to time, place and person.

VITALS 
BP - 110/90mmhg
Pressure - 78bpm
Temperature-afebrile 
Pulse rate - 102
Resp rate - 20 cpm 
GRBS -94
Spo2 - 100%

No pallor 
No icterus
No cyanosis
No clubbing
No generalised lymphadenopathy
No pedal edema

SYSTEMIC EXAMINATION
RS-bae+
CVS- S1 , S2+

Provisional diagnosis :
Splenomegaly with ascites 


Treatment:- 
Tab dolo 650 mg TID
Injection neomol IV
Inj pan 40 mg
Monitor bp, spo2 and temperature 
Inj vit B12 1500ml mg in 100ml NS over 1hr.

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