Medicine case

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A  33 year old male came to the casuality with chief complaints of :

Abdominal distension since 2 months

B/L pedal edema since 2 months

Scrotal swelling since 2 months 

History of present illness:

Patient was apparently assymptomatic since 3 years back. 3 years back he had history of abdominal distension and pedal edema for which he visited local hospital and was diagnosed as liver disease and used medication for a while and stopped , he was diagnosed as diabetic back then and on treatment metformin 500 mg .

He was separated from his wife five yrs back. 

8 months back :

He had abdominal distension and yellowish of eyes and used herbal medication - he did not get any relief for it , his symptoms got aggravated then he visited other hospital with abdominal distension and SOB at rest , back then he was diagnosed as DCMP secondary to alcoholism with Chronic Liver Disease with Alcohol Dependence Syndrome with DM - 2 

Patient stopped taking medication since 2 months followed by pedal edema which was insidious in onset and gradually progressive till the scrotum and abdominal distension till the xiphisternum .

Past history:

He was suffering from diabetes since 2 yrs and on medication -Metformin

Chronic liver disease since 3 years. 

Pedal odema since 2 months. 

Last alcohol intake was 6 days ago. 

Personal history : 

Occupation - sells plants 

Diet - mixed 

Appetite - decreased since 5-6 days 

Sleep - decreased quality of sleep due to pain 

Bowel and bladder habits - regular 

Addictions : smoking since 10 years 

Alcohol since 10 years

Family history:

No relevant family history. 

General examination : Conscious and coherent and cooperative,Orienteted to time,person and place

Pallor:Absent 

Icterus:Present

Cyanosis:absent

Clubbing:absent

Lymphadenopathy:absent

Edema:present(pitting type)

Vitals:

Temp - febrile (99.2 degree Fahrenheit)

PR - 112 bpm

RR - 22 cpm

BP - 110/70 mmHg 

SPO2 - 99 % at RA

GRBS - 175 mg/dl 

Systemic examination : 

CVS : 

S1 S2 + 

JVP - elevated 

No parasternal heave /thrills 

Apex beat - 5th ICS

Other findings:

Normal hernial orifices 

Fluid thrill + 

Hemogram :

HB - 13

TLC - 12,100

N/L/E/M - 67 /20/10/3

PCV - 37.8

PLt - 3.13

RBC - 4.81 

RFT :

Urea - 31 

Creatinine - 0.7

Uric acid - 2.7

Calcium - 10 

Phosphorous - 3.8

Sodium - 130 

Potassium - 3.6

Chloride - 91 

LFT : 

TB - 7.26 

DB -4.21

AST - 26 

ALT - 17 

ALP - 560 

TP - 6.6 

Albumin - 3.6 

A/G ratio - 0.24 

Diagnosis : 

HFrEF with Chronic Liver Disease with DM type -2

 Treatment : 

1.fluid restriction <1.5 l /day 

2.salt restriction <2.4 g/day

3.Tab Lasix 40 mg po/bd 

4.Tab Aldactone 50 mg po od 

5.Tab Met xl 12.5 mg po bd 

6.Tab Thiamine 100 mg po bd

7.daily weight and abdominal girth monitoring 

8.I/O charting 

9.Monitor vitals -4th hourly

10.Grbs - 6th hourly 

11.inj HAI s/c according to sliding scale

 present