56/M with pain in 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% 

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.