General medicine case presentation

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Date of admission: 20/11/2021

A 44   year old male  who is  farmer by occupation came to casuality with cheif complaint of swellings in limbs since 1 month  ,abdominal distension since 3 months.

History of present illness:

Patient was asymptomatic 10 years back .He underwent dipression and addicted to alcohol . 9 years back due to  severe dipression he committed suicide by swallowing poison and admitted in KIMS .nkp.1 year after he again commited suicide by taking sleeping pills and admitted into hospital and treated accordingly.5 years back he had pain in abdomen following which he diagnosed with cholelithiasis for that laparoscopic cholerystectomy done.for which he had multiple admissions for abdominal pain following alcohol consumption since 4-5 years back. 

2 years back patient developed yellowish discoloration of sclera and urine for which he diagnosed as chronic liver disease.

3 months back patient developed abdominal distension , pedal edema for which he admitted in narketpally KIMS ascitic tap done evaluated and treated  accordingly and discharged. 10 days after discharge patient again developed ascites and pedal edema for that he taken to Hyderabad where again ascitic tap was done .

In view of thrombocytopenia  platelets transfusion done and 4 vials of albumin was transferred.25 days hospitalized with 10 days in patient was discharged and readmitted  .

 Now patient brought to casuality with similar complaints of pedal edema and abdominal distension.

Past medical history:

Patient is not a known case of Asthama, epilepsy,  Tuberculosis.

Personal history:

Diet : mixed

Sleep:reduced

Apettite: decreased

Bowel and bladder movements: regular

Micturation: normal

Habits : chronic alcoholic.

No known allergies.

Patient is a known case of Diabetesmellitus since 10 years.

Drug history :

Patient is not allergic to any known drugs.

Family history: 

No similar complications in the family members

General examination:

Patient is conscious, coherent,cooperative to time and place.

Patient is moderately built

Patient is not pallor

No generalized lymphadenopathy

No clubbing of fingers

No cyanosis

No icterus

Bilateral pedal edema is present

Vitals :

Temperature: Afebrile

Pulse rate 90 beatsper minute

Respiration rate: 20 cycles per minutes

Blood pressure: 130/90

Spo2 : 97%

GRBS : 95 mg %

Systemic examination:

Cardiovascular system:

Auscultation:

S1 S2 sounds heard

Palpation :JVP is normal

No murmers heard

No Thrills

Respiratory system:

Position of trachea central

Vesicular breathing sounds 

No dysopnea

No wheezing.

Abdomen :

Shape of abdomen Distended

Tenderness is present

abdominal spleen is palpable masses found

No bruits.

Umbilicus is everted

Central nervous system

Patient is conscious coherent and cooperative to time and place.

Speech is normal

Reflexes are normal 

Investigations:

20/11/2021:

Rapid test for COVID: negative

BT: 2:30

CT: 5:00

Hb: 8.4 gm/dl

TC: 7000

PCV: 23.8

PLC:1.10

INR: 1.77

Urea:32

S creatinine : 0.7

Na ions: 142

K ions: 3.1

Chloride : 9.8

Ascitic sugar:90

Ascitic protein: 1.2

Ascitic CDC: 150

SAAG:

S albumin : 2.4

Ascitic albumin: 0.5

SAAG: 1.9

Ascitic fluid amylase: 39

Provisional Diagnosis:

Cirrhosis of liver.

Treatment:

1) TAB LASIX 40 mg PO/ BD

2) TAB ALDACTONE 50 mg OD

3) PROTEIN- X POWDER 2 Scoops in 100 ml milk

BD

4) BP, PR, TEMPERATURE MONITORING 4th hourly

5) INJ. THIAMINE 1 amp in 100 ml NS IV/ OD

6) INJ. OPTINEURON 1 amp in 100 ml NS IV/OD

7) DAILY BODY WEIGHT AND ABDOMINAL GIRTH MONITORING

8) STRICT I/O CHARTING

9) FLUID RESTRICTION (< 1.5 L/ day) and SALT RESTRICTION (<2.4 g/ day)