40 year old male patient

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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(discomfort when breathing while lying down) - present 

No PND.

Dry cough - Present 

- 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 these complaints, used medications prescribed by them for 1 month & was 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

Generalised edema and edema on hands

Per abdomen : no organomegaly seen .no tenderness , guarding / rigidity 

Bowel sounds : present.

VITALS:

On 25.09.2021

Temperature- Afebrile

Pulse rate : 72 bpm

Respiratory Rate: 18 cycles per minute

Blood Pressure: 140/90mm Hg

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

First and second heart sounds heard. No murmurs

RESPIRATORY SYSTEM: 

Bilateral Air entry present. 

CENTRAL NERVOUS SYSTEM:

Higher motor functions intact

PER ABDOMEN EXAMINATION:

Abdomen - distended

Diffuse tenderness - present 

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

ELECTROCARDIOGRAPHY: 

ULTRASONOGRAPHY:

FEVER CHART:

DIAGNOSIS :

CHRONIC LIVER DISEASE ON EVALUATION UNDER ANASARCA 

TREATMENT:

ON 25.9.2021

1. FLUID RESTRICTION LESS THAN 1.5LIT/DAY

2. Inj. LASIX 40 mg IV BD

3. Tab. ALDACTONE 50mg PO OD

4. ABDOMINAL GIRTH MONITORING 

5. MONITORING VITALS 4TH HOURLY

6. MONITORING GRBS 12TH HOURLY

ON 26.09.2021

Temperature- Afebrile

Pulse rate : 74 bpm

Respiratory Rate: 18 cycles per minute

Blood Pressure: 130/80 mm Hg

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