General Medicine Case 1

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Date of admission:8/12/2021

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 

HOPI : 

33 year old male got married 9 years back , separated from his wife and children since 5 years due to family issues . 

After separation with his wife  ,patient started taking half a bottle of whisky every day .

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.

Past history : 

He's a k/c/o DM -2 since 2 years and under treatment of Tab Metformin 500 mg 

K/c/o HFrEF since 6 months   , Chronic liver disease since 3 years 

Not a k/c/o tuberculosis , asthma ,epilepsy .

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 significant family history 

General examination : 

 Mild icterus present 

Edema of feet - present 

Scrotal swelling + abdominal distension 

No H/O pallor , cyanosis , lymphadenopathy

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 : 

RS :

BAE + , NVBS heard 

P/A : 

Abdomen - distended 

No tenderness 

No palpable mass 

No organomegaly 

No bruit hear

CNS - no focal neurological deficit present 

Diagnosis : 

HFrEF with Chronic Liver Disease with DM type -2 

Investigations : 

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 

Ultrasound : 

1.altered echotexture of liver with mild surface irregularity ?chronic liver disease 

2.Raised echogenicity of B/L kidneys 

3.Gall bladder wall edema 

4.Gross ascites

5.Skin and subcutaneous tissue shows edematous changes in the anterior abdominal wall diffusely 

Chest x-ray pa view 

ECG 

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