A 27yr old patient came with chief complaints of pedal Edema since 10 days
CHIEF COMPLAINTS-
C/o loss of appetite since 20 days
C/o tremors since 15 days
C/o blood in urine since 10 days and
C/o pedal edema since 10 days
HISTORY OF PRESENT ILLNESS-
Patient was apparently asymptomatic 20 days back then he had loss of appetite for which he went to the hospital and was diagnosed as CLD spleenomegaly and portal hypertension for which he took medication after which he developed haematuria since 10 days and pedal Eden’s which is of pitting type.
Pedal edema is relieved by taking test and increases on walking. He had developed tremors since 15 days and Malena 20days ago for 10 days.
He complained of decreased sleep since 1 month.
No c/o abdominal pain, vomiting, loose stools,burning micturition.
HISTORY OF PAST ILLNESS-
He had similar complaints in the past (1 yr ago)
Not a known case of DM, HTN, Epilepsy, TB, CVA, CAD.
SURGICAL HISTORY-
H/o appendectomy 4 yrs back.
PERSONAL HISTORY-
Appetite- lost since 20 days
Non-vegetarian
Bowels- regular
Micturition- haematuria since 10 days
Addictions-
Alcohol- regularly since the past 6 yrs. increased intake since last 2yrs. 1/2 bottle per day twice Addictions-
Alcohol- regularly since the past 6 yrs. increased intake since last 2yrs. 1/2 bottle per day twice daily
FAMILY HISTORY-
Father is a chronic alcoholic.
PHYSICAL EXAMINATION-
GENERAL EXAMINATION-
Pallor- No
Icterus- yes
Cyanosis-No
Clubbing- yes
Lymphadenopathy- No
Odema of feet- yes (grade 1)
Temperature-
Pulse rate- 90/ min
Respiration rate-
Blood pressure-100/60 mm hg
GRBS-122%
SYSTEMIC EXAMINATION-
CVS-
Thrills- No
Cardiac sounds- s1s2 heard
Cardiac murmurs- No
RESPIRATORY SYSTEM-
Dyspnoea- No
Wheeze- No
Breath sounds -vesicular
ABDOMEN-
Shape of abdomen- scaphoid
Tenderness- not present
Palpable mass- not present
Free fluid- not present
Liver- not palpable
Spleen- not palpable
CNS-
Level of consciousness- consciousness
Speech- normal
PROVISIONAL DIAGNOSIS-DECOMPENSATED LIVER DISEASE - grade 1 ( hepatic encephalopathy)
HYPOTONIC HYPONATREMIA - diuretic induced.
TREATMENT-
Rx
IV fluids NS 75ml/hr
Inj vitamin K 10 mg IV/OD
Inj Thiamine 200 mg IV/BD in 100 ml NS
T Doxy 100 mg PO/BD
T Udiliv 300 mg PO/ BD
T Viboliv 500 my PO/BD
Syp. Hepamerz PO/T/ID.