patient with portal hypertension

This is 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 patients clinical problems with collective current best evidence based inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.
 
A 56 years old age male patient came to the opd with cheif conplaint of abdomen pain since 5days 

History of present illness :-
    patient was apparently asymptomatic 4days ago then he developed pain in the abdomen (upper abdominal region) History of distended abdomen since 4 days 
No history of nausea, vomiting , fever ,  constipation 
History of last alcohol taken 5 days back 

History of past illness :- 

No known history of  DM, HTN, Asthama, epilepsy, Lymadenopathy

Personal history :- 
Apetite - normal 
Diet - mixed 
Bowel and bladder movememts - regular 
Micturation :- burning micturation 

Drug allergy :- No known history of drug allergies

Addictions :- No addictions

Family history :- no known member of the family has similar complains 

GENERAL EXAMINATION :- 

No pallar 
No icterus 
No cyanosis 
No Clubbing of fingers 
No lymphadenopathy 
No Odema of the feet 

Vitals :- 
Temp :- 98.4 F 
Pluse rate :-  102 / min 
Res rate :-  20 / min 
BP :- 120/90 mm/hg 
Spo2 :- 98%

SYSTEMIC EXAMINATION :- 
CVS :- 
No thrills 
Cardiac sounds : S1S2 +
No cardiac murmurs 

RESPIRATORY SYSTEM :- 
No Dysponea
No wheeze 
No deviation of trachea 
Vascular breath sounds 

ABDOMEN :- 
Shape :- distended
No tenderness 
No palpable mass 
Normal hernial orifices 
No free fluid 
Liver non palpable
Spleen not palpable 
Bowels sounds are normal 

Provisonal diagnosis :-  pain in abdomen decrease exudation

Clinical diagnosis :-




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