General medicine case 09

 General medicine case 09

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A 48 year old male who work as farmer resident of Narketpally came to casualty with Chief complaints of bilateral pedal edema since 3 months, abdominal distension since 3 months.

History of Present illness:-

Patient was apparently asymptomatic 10 years ago following which his son had depression in his 10th grade due to which patient underwent depression and got addicted to alcohol.9 years back he had severe depression and committed suicide by swallowing poison and admitted in KIMS,NKP and got treated and diagonosed with DM 8 years ago.He again committed suicide by swallowing sleeping pills and was treated accordingly.5 years back he had pain abdomen following which he was diagnosed with cholelithiasis and underwent ? laparoscopic cholecystectomy,then after he had multiple admissions for pain abdomen following alcohol consumption (?4/5 admissions per year).

2 years back pt developed yellowish discoloration of sclera and urine following which he was diagnosed with chronic liver disease.

3 months back pt developed abdominal distension with pedal edema admitted in NKP,Ascitic tap was done and evaluatted accordingly and discharged.10 days after discharge he again developed Ascites and pedal edema and then went to Hyderabad where Ascitic tap was done again.

I/v/o thrombocytopenia 8 pint RDP was transfused amd 4 units of Albumin (?) Was transfused.15 days hospitalized with 10 days in between patient was discharged and readmitted.

Now pt brought to casualty with similar complaints of pedal edema,gross distension of abdomen since 20 days.

Past History:-

Patient was diagnosed with DM since 8 years.

Not a know case of Hypertension, Tuberculosis, Asthma, CVD , Epilepsy.

Personal History:-

Sleep is adequate.

Appetite is normal

Takes mixed diet.

Bladder and bowel movements are regular.

Patient consume alcohol regularly (180-250 ml per day)

Family history:- 

No family members has similar complaints.

Treatment History :-

Patient is on oral hypoglycemic drugs.

General history:-

Patient was conscious, coherent, well oriented to place and time.

No anemia, no pallor, no cyanosis, no icterus , no clubbing, no generalised lymphadenopathy.

Vitals:- 

Temperature--98.2 °F

Respiratory rate-- 20 cpm

Pulse rate --90 bpm

Blood pressure--130/90 mmHg

Systemic Examination:-

CVS -- s1 ,s2 heard

Respiratory system-- BAE+

P/A -- Distended , non tender

CNS--- NFD

Investigations:-

Hb - 8.4 gm/dl

TC - 7000

PCV - 23.8

PL.C - 1.10

PT - 24

APTT - 24 sec

INR 1.77

S.Urea - 32

S.creat 0.7

Na - 142

K - 3.1

Cl - 98

Ascitic sugar - 90

Ascitic protein - 1.2

Ascitic LDH - 150

S. Albumin - 2.4

Ascitic albumin - 0.5

SAAG - 1.9

Ascitic fluid amylase - 39

RBS - 79

Provisional diagnosis:-

CHRONIC LIVER DISEASE WITH GROSS ASCITIS.INGUINO SCROTAL SWEELING WITH SCROTAL EDEMA

Treatment :-

1)T.LASIX 40 MG PO/BD

2)T.ALDACTONE 50 MG PO/OD

3)PROTEIN X POWDER 2 SCOOPS IN 100ML MILK

4)INJ.THIAMINE 1 AMP IN 100ML NS IV/OF

5)INJ.OPTINEURON 1 AMP IN 100 ML NS IV/OD

6) DAILY BODY WEIGHT AND ABDOMINAL GIRTH MONITORING

7) STRICT I/O CHARTING

8) FLUID RESTRICTION <1.5 LITRES PER DAY

9)SALT RESTRICTION <2 GM/DAY

10) GRBS CHARTING 8TH HOURLY