A 28 year old male with Gross Ascites
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A 28 year came to OPD with
C/o Abdominal distention since 10 days
Abdominal discomfort since 10 days
History of Presenting illness
Patient was apparently asymptomatic 10 days ago then he developed Abdominal discomfort and distention of abdomen for which he visited a primary health care centre near his residence where he was adviced to get an Xray of Abdomen for which he visited our Institution. Abdominal distention was insidious in onset and gradually progressed to current size
Patient complaints about Abdominal discomfort while talking and also after eating therefore patient is restraining from eating even though he is hungry
No h/o Nausea, Vomiting, Loose stools, Constipation
No h/o Melena, Hematuria, Burning micturition
Past History
No h/o similar complaints in the past
N/k/c/o DM, HTN, Asthma, TB, Epilepsy, Thyroid disorders, CAD, CVD.
H/o Jaundice 15 years ago
Underwent Appendicectomy 20 years ago
Underwent surgery for Hydrocele 16 years ago
Personal history
Patient is married and has 3 kids
He is daily wage labourer
Appetite is Normal
Diet is Mixed diet
Sleep Inadequate due to abdominal discomfort
Bowel and bladder movements regular
Addictions - Alcohol consumption since 2 years
Consumes alcohol 2-3 times a week
Occasional toddy drinker
Chews Gutka
Family history
No similar complaints in the family
General Physical Examination
Patient was Conscious, Coherent and Cooperative.
Well oriented to time, place and person.
Moderately built and Undernourished
No Pallor, Icterus, Cyanosis, Clubbing, Koilonychia, Generalised Lymphadenopathy
Vitals
Temperature - Afebrile
Pulse - 84 bpm
Respiratory rate - 17 cpm
Blood pressure - 110/70 mmHg
Systemic examination
CVS - S1,S2 heard
RS - BAE +, Dyspnoea on exertion present
CNS - No focal neurological deficits
Abdomen
On Inspection
Abdomen is distended
Umbilicus is central and inverted
Skin is stretched with Dilated veins on sides of the Abdomen
Appendicectomy scar present
On Palpation
Soft, Nontender
Liver not palpable
Spleen not palpable
On Percussion
Shifting dullness present
Fluid thrill elicited
Liver span was difficult to percuss due to distended abdomen.
Auscultation - Bowel sounds present
Provisional Diagnosis - Ascitis secondary to Chronic aliver disease
Diagnostic ascitic tap reveals Hemorrhagic Ascitis
My own AETCOM analysis of this patient :
ReplyDeleteAttitude leading to failed communication toward patient's
1) Diagnosis :
Attitudinal failure to learn how to diagnose his pain abdomen
There was considerable uncertainty about his abdominal pain and ascites but given the sequence of events, it looked like an inflammatory ascites either secondary to a sealed perforation and secondary peritonitis or even remotely peritoneal tuberculosis
Instead of trying to seek help from different team members by communicating it to all the stakeholders in time, I just limited my sharing of the patient's problems with very few people and hence failed to arrive at a diagnosis.
The next step would have been an exploratory laparoscopy to look for sealed perforation with peritoneal biopsy but I failed to realize that as I had limited my communication of this patient with other departmental team members
Ethics :
I sent the patient to some other place and forgot totally about him and didn't learn what was done for him finally and as a result I shall repeat the same AETCOM failure again given the same situation of pain abdomen!