30 year Male came to OPD with Pedal edema and abdominal distension.

September 23, 2021

30 year old male came to OPD with Pedal edema and abdominal distension since 10 days.

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30 year old male came to OPD with Pedal edema and abdominal distension since 10 days.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 1 year and then he developed pedal oedema is insidious in onset,gradually progressive.

Bilateral pitting type associated with abdominal distension.

1 year back he had pain abdomen - diffuse type, not associated with vomitings - stopped drinking due to pain and got treatment from local RMP.

After the pain subsided, he started drinking again.

2 months back,there is H/O yellowish discoloration of eyes, bilateral pedal edema, pain abdomen

PAST HISTORY:

H/O of RTA in 2007 which led to leg fracture.

H/O of RTA in 2013 due to which he went into coma for 3 days.

2 years back he was diagnosed with Fatty liver.

Patient was COVID Positive 4 months back.

3 months back he was admitted in our hospital with similar complaints and he was treated with

1)Tab.lasix 40 Mg ,PO/OD

2)Tab.Aldactone 50 mg BD

3) Tab.Pantop 40mg PO/OD

4)Tab.Udiliv 300mg PO/OD

5)Syp.Hepamerz BD

On 06/08/2021:

Hb:7.5gm/dl

Tlc:28000

LFT:

Total bilirubin:13.18mg/dl

Direct Bilirubin:7.16mg/dl

ALP:181

Albumin:2.24

A/G:0.61

Not a K/C/O HTN/DM/BA/TB/Epilepsy/CAD

PERSONAL HISTORY:

Diet- mixed

Sleep-adequate

Appetite-decreased

Bowel and bladder habits- irregular

Addictions-

Alcohol: Regular intake of 180-360 ml/day since 10 yrs -- stopped 4 months back

Smoking: 5-6 per day since 10 yrs -- stopped 4 months back.

FAMILY HISTORY:

Not Significant

GENERAL EXAMINATION:

Pt is C/C/C

Mild pallor present

Icterus present

Bilateral Oedema-pitting type of feet

Mild Malnutrition

No clubbing/koilonychia/lymphadenopathy

Vitals:

Afebrile,

BP;120/70mmhg

PR:100Bpm

RR:19Cpm

Spo2:98%

SYSTEMIC EXAMINATION:

CVS:

S1 S2 heard

No murmurs

RS:

BAE+

NVBS+

Trachea-central

No added sounds

No dyspnoea/wheeze

CNS: NAD

P/A:

Shape of abdomen-distended

Hernial orifices normal

No tenderness or palpable mass

Shifting dullness+

Liver and spleen not palpable

Bowel sounds heard

INVESTIGATIONS:

23/09/2021

1. Hemogram:

- Hb= 6.8 gm%

- TLC= 10,300

- PCV= 20.1

- MCH= 34.5

- RBC= 1.97 million/cc

- PLATELETS= 1.70 lakhs/cumm

3.Serum Electrolytes:

Sodium= 135 mEq/L

Potassium= 4 mEq/L

Chloride= 102 mEq/L

4. LFT:

Total bilirubin=4.55

Direct bilirubin=3.05

SGOT=37

ALP=338

Albumin=2.0

Total Protein:5.0

A/G Ratio=0.66

PT-18sec

INR:1.2

Aptt:36sec

Blood urea:16

Sr creatinine:0.8

Sr LDH:290

Sr.iron:62

Sr.ferritin:595

Sr.albumin:2.6

Ascitic Fluid;

Sugar:172

Protein:1.1

Amylase:8.6

LDH;47

Albumin:0.43

SAAG:2.17

Ascitic fluid cytology:

TC:15 cells

L:90%

N:10%

RBC: Few

ECG:

Chest xray:

Ultrasound:

Provisional diagnosis:

Chronic Liver disease secondary to alcohol

TREATMENT GIVEN:

1. Fluid restriction <2 L/day

2. Inj. Lasix 40 mg IV BD 8am and 4 pm

3. Tab. Spironolactone 500 mg OD at 8 am

4. Inj. Thiamine 100 mg in 100 ml NS IV TID

5. Weight monitoring daily

6. Abdominal girth daily

7. Input/Output charting

8. 2 egg whites/day

9. Proteiney powder 2 scoops in 1 glass

Soap notes:

24/09/2021

Subjective- Pedal edema present and abdominal distension present

Objective

Temp: 100F

Bp: 120/70 mm hg.

PR:86bpm

GRBS: 112mg/dl.

Spo2:99%

Abdominal girth:78cm

Weight:51.4kgs

Assessment

Chronic liver disease secondary to alcohol.