A 66yr old male with ascites secondary to ??

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.


 A 66 YR OLD MALE  CAME WITH C/O ABDOMEN DISTENSION SINCE 20-30 DAYS, PAIN ABDOMEN SINCE 1 WEEK,  CONSTIPATION SINCE 2 DAYS, DECREASED URINE OUTPUT SINCE 2 DAYS
PATIENT WAS APPARENTLY NORMAL 1 MONTH BACK THEN HE DEVELOPED ABDOMINAL DISTENSION WHICH IS PROGRESSIVE AND ASSOCIATED WITH PAIN ABDOMEN SINCE 1 WEEK, CONSTIPATION ANS DECREASED URINE OUTPUT SINCE 2 DAYS

PAST HISTORY:
NOT A K/C/O HTN,DM,CAD,ASTHMA,TB
H/O TRAUMA TO LEFT LEG 5 YR BACK

PERSONAL HISTORY:
OCCASIONALLY TAKES ALCOHOL
GUTKA CHEWER
NON SMOKER
HIS APPETITE IS NORMAL
MIXED DIET

ON EXAMINATION:
PT IS C/C/C
NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, PEDAL EDEMA

VITALS:
TEMP- AFEBRILE
PR- 100 bpm
BP- 120/80 mmHg
RR- 16 cpm
GRBS- 99 mg/dl

P/A:
SHAPE- DISTENDED
TENDERNESS- PRESENT
FREE FLUID PRESENT
NO ANY PALPABLE MASS
HERNIAL ORIFICES ARE NORMAL
NO BRUIT
LIVER AND SPLEEN ARE NOT PALPABLE
BOWEL SOUNDS PRESENT
ABDOMINAL GIRTH 87 cm
WEIGHT 57 Kg
P/R: RECTUM LOADED WITH FAECES
CVS: S1S2 + NO MURMURS
RS: BAE+ NVBS+
CNS: NFD

DIAGNOSIS: HEMORRHAGIC ASCITES SECONDARY TO CHRONIC PANCREATITIS?

Ascitic tap done on admission (05/11/2021)
2nd ascitic tap done on 06/11/2021:




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