1701006020 CASE PRESENTATION
LONG CASE
Abdominal Distension since 1 year
Facial puffiness since 1 year
Itching all over the body since 1 year and developed multiple plaques on hips, buttocks, abdomen and dorsal of feet.
Sob since 5 days
pedal edema since 5 days which is of pitting type
H/O PRESENT ILLNESS
Patient was apparently asymptomatic 1 years back then she developed abdominal distension, facial puffiness,itching all over the body and 5 days ago she developed pedal edema and SOB grade 3.
she developed B/L Knee pain - since 3years, onset - insidious, gradually progressing, type- pricking, more at the night, aggravated on walking, relieved on sitting n sleeping, no radiation and is under medication( demisone 0.5 mg and acelogic SR)
Not a K/C/O DM/HTN/ asthma / Ischemic heart disease / epilepsy / TB
FAMILY HISTORY
NO SIGNIFICANT FAMILY HISTORY
PERSONAL HISTORY:
OCCUPATION Daily wage worker
DIET MIXED
APPETITE decreased
SLEEP NORMAL
BOWEL AND BLADDER HABITS : decreased urine output
ADDICTIONS: NO
GENERAL EXAMINATION
Patient is concious coherent and coperative, well oriented to time palce and person
VITALS
BP 110/80
PR 90bpm
TEMP 98.5degrees F
SPO2 98 @ RA
GRBS 106
NO PALLOR, ICTERUS , CYANOSIS, CLUBBING , LYMPHADENOPATHY ,
SYSTEMIC EXAMINATION
CVS-S1 S2+ heard , no murmurs
P/A-SOFT, NON TENDER, NO ORGANOMEGALY
RS - BAE + , normal vesicular breath sounds
50 year old male, farmer by occupation, resident of Pochampally, came to Medicine OPD with complaints of :
* Distended abdomen since 7 days
* Pain abdomen since 7 days
* Pedal edema since 5 days
* Breathlessness since 4 days.
HISTORY OF PRESENT ILLNESS:
The patient was apparently asymptomatic 6 months ago when he developed jaundice and was treated at a private practitioner.
Later he developed abdominal distension about 7 days ago - insidious in onset, gradually progressive to the present size - associated with
Pain in epigastric and right hypocondrium - colicky type.Fever - high grade, not associated with chills and rigor, decreased on medication, No night sweats.Not associated with Nausea, vomiting, loose stools
There was pedal edema
Gradually progressive Pitting typeBilateral Below kneesIncreases during the day - maximum at evening.No local rise of temperature and tenderness Grade 2 Not relived on rest
He also complained of shortness of breath since 4 days - MRC grade 4
Insidious in onsetGradually progressive Agrevated on eating and lying down ; No relieving factorsNo PNDNo cough/sputum/hemoptysisNo chest painNo wheezing
Patient is a known alcoholic since 20 years. Ascites increased after his last drink on 29th May, 2022.
Daily Routine :
Wakes up at 5am and goes to field.
Comes home at 8am and has rice for breakfast. Returns to work at 9am.
1pm - lunch
2-6 pm - work
6pm - home
8pm - dinner
Alcohol- 2 times a week, 180 ml.
PAST HISTORY:
No history of similar complaints in the past
Medical history- not a known case of DM, HTN, TB, Epilepsy, Asthma, CAD
Surgical history - not significant
PERSONAL HISTORY:
Diet - mixedAppetite- reduced since 7 daysSleep - disturbedBowel - regularBladder - oliguria since 2 days, no burning micturition, feeling of incomplete voiding. Allergies- noneAddictions - Beedi - 8-10/day since 20 years ;
- Alcohol - Toddy - 1 bottle, 2 times a week, since 20 years;
- Whiskey-180 ml, 2 times a week, since 5 years.
- Last alcohol intake - 29th May, 2022.
FAMILY HISTORY:
Not significant
GENERAL EXAMINATION
Patient is conscious, coherent and co-operative.
Examined in a well lit room.
Moderately built and nourished
Icterus - present (sclera)
Pedal edema - present - bilateral pitting type grade 2
No pallor, cyanosis, clubbing, lymphoedenopathy.
PROVISIONAL DIAGNOSIS:
Acute decompensated liver failure with ascites.
TREATMENT:
Syp. Lactose 15ml TID
Abdominal girth charting - 4th hourly
Fluid restrictriction less than 1L per day
Salt restriction less than 2 gms per day
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