1702102065 LONG CASE
A 40 year-old man, who is a auto driver by occupation, presented to the hospital with
- Generalised swelling & swelling of hands & legs since 1 week
HISTORY OF PRESENT ILLNESS
Patient came to the casuality with pedal edema since 1week,which was Insidious in onset, gradually progressed to upper abdomen & developed anasarca associated with Shortness of breathe(SOB) (GRADE-IV),
Orthopnoea(discomfortwhen breathingwhile lying down) - present
Dry cough - Present
PND(paroxysmal nocturnaldyspnoea) - Absent
- H/O daily intake of alcohol since 13 yrs (daily 90- 180ml) present
No h/o trauma, no c/o giddiness, headache, chest pain, burning micturition, pedal edema. No c/o nausea, vomiting.
PAST HISTORY
-Patient was apparently asymptomatic 2 years back, then he had pedal edema which is bilateral Pitting type, Insidious in onset, gradually progressive, upto knee region. Patient visited yasodha hospital with this complaints, used medications prescribed by them for 1 month & adviced to quit alcohol.but patient didn't quit alcohol
Not a known case of Hypertension, Diabetes, Tuberculosis, Epilepsy, Cardiovascular Accident, Coronary artery disease.
PERSONAL HISTORY
-Appetite:Normal
Diet: mixed
Sleep: Adequate
Bowel & Bladder movements: Regular
Addictions: He is a known alcoholic since 13 yrs (daily 90-180ml)
FAMILY HISTORY: Insignificant
GENERAL PHYSICAL EXAMINATION:
Patient was conscious, coherent and cooperative
moderately built and moderately nourished.
Pallor- no pallor
Icterus- no icterus
Cyanosis- no cyanosis
Clubbing- no clubbing
JVP - Elevated
Generalised lymphadenopathy- no generalised lymphadenopathy
-pedal edema: B/L pitting type upto knee
And generalised edema and edema on hands.
Per abdomen : no organomegaly seen .no tenderness , guarding / rigidity
Bowel sounds : present.
VITALS:
Temperature- Afebrile
Pulse rate : 72 bpm
Respiratory Rate: 18 cycles per minute
Blood Pressure: 140/90mm Hg
SYSTEMIC EXAMINATION:
CARDIOVASCULAR SYSTEM:
S1 S2 heard.
No murmurs
RESPIRATORY SYSTEM:
Bilateral Air entry present.
CENTRAL NERVOUS SYSTEM:
Higher motor functions intact
PER ABDOMEN EXAMINATION:
Abdomen - distended
Diffuse tenderness present
Shifting dullness present
Bowel sounds heard
INVESTIGATIONS:
RENAL FUNCTION TEST:
Blood urea: 13mg/dl
Serum Creatinine: 1mg/dl
Na+ : 141 mEq/L
K+ : 4.3 mEq/L
Cl- : 99 mEq/L
RANDOM BLOOD SUGAR : 127 mg/dl
COMPLETE BLOOD PICTURE:
Hemoglobin- 13.5g/dl
Total Leukocyte count - 9700/mm³
Neutrophils- 71%
Lymphocytes-19%
Eosinophils - 4%
Monocytes- 6%
Platelets- 3.20 lakhs/mm³
LIVER FUNCTION TEST:
Total bilirubin- 4.01 mg/dl
Direct bilirubin- 1.47 mg/dl
AST - 50 IU/L
ALT- 31 IU/L
AST:ALT - 1.6
ALP- 486 IU/L
Total protein- 5.8 g/dl
Albumin- 3.6 g/dl
Albumin:Globulin - 1.64
COMPLETE URINE EXAMINATION:
Albumin - nil
CHEST X-RAY:
ELECTROCARDIOGRAPHY:
ULTRASONOGRAPHY:
FEVER CHART:
DIAGNOSIS :
CHRONIC LIVER DISEASE
RIGHT HEART FAILURE
TREATMENT:
1. FLUID RESTRICTION LESS THAN 1.5LIT/DAY
2. SALT RESTRICTION LES THAN 2g/day
3. Inj. LASIX 40 mg IV BD
4. Tab. ALDACTONE 50mg PO OD
5. ABDOMINAL GIRTH MONITORING
6. MONITORING VITALS 4TH HOURLY
7. MONITORING GRBS 12TH HOURLY
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