General medicine case 1
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A 31 year old male patient came to the opd with the chief complaints of abdominal distention,pain abdomen,pedal edema.
HISTORY OF PRESENT ILLNESS:
Patient is apparently asymptomatic 1 year back then he had pain in abdomen which is of diffuse type not associated with vomiting. He stopped drinking due to the pain and got treatment from local RMP for the pain. After the pain has subsided he started to drink again. He had multiple attacks of pain in abdomen since 1 year. 2 months back he had a c/o yellowish discoloration of eyes,pain in the abdomen and b/l pedal edema for which he got treated in NIMS,his symptoms subsided within 2 days. Then he was tested positive for covid-19 by RTPCR test for which he referred to Gandhi hospital and took medication for 10 days and went back home. By that time yellowish discoloration of eyes was still present. 20 days back there was insidious onset of abdominal distention pedal edema extending upto knees and fever (intermittent, low grade,relieves with medication)since 4 days for which he got treated in our hospital. He was asymptomatic for 15 days followed by c/o pedal edema b/l type extending upto knees (pitting type) since 3 days. Diagnostic and therapeutic ascetic tap was done.
PAST HISTORY:
No h/o pain abdomen, distension, fever, vomiting, loose stools.
No h/o diabetes mellitus, hypertension, asthma, epilepsy, tuberculosis.
He met with an accident in 2007 and 2014 with head injury.
PERSONAL HISTORY:
Diet- mixed
His bowel and bladder movements are normal.
He was a regular alcohol drinker since 10 years stopped 2 months back.
Regular smoker 5-6 per day since 10 years.
TREATMENT HISTORY:
No history of drug allergies.
Treatment was taken for present illness.
GENERAL EXAMINATION:
On examination patient is conscious, coherent, cooperative.
No pallor
No cyanosis
No clubbing
No generalized lymphedenopathy
Icterus -present
Bipedal edema-present
VITALS:
Temperature-97.4 F
Pulse rate-80 bpm
Respiratory rate-20 cpm
B.P-110/90
SpO2-98%
SYSTEMIC EXAMINATION:
•CVS-
S1 S2 heard
No murmurs.
•Respiratory system-
Bae present,no abnormalities
•Per abdomen-
Liver palpable,non tender
•CNS-
No focal nuerological deficts
PROVISIONAL DIAGNOSIS:
Chronic liver disease with grade 1 varices.
INVESTIGATIONS:
Blood urea
Serum creatinine
Serum electrolytes
Liver function test
Complete blood picture
APTT:
PROTHROMBIN TIME:
TREATMENT:
Vit k -10mg od
Tablet udiliv-300mg bd
Syrup Hepamerz -10ml
Syrup Lactulose,lasix -20ml
Tab.Aldactone-25 mg bd and was discharged on 9/8/21 in a hemodynamically stable condition.
DAY-1:
Fluid and salt restriction
Inj.Thiamine 1 amp in 100 ml NS IV/tid
Inj.vit k 10mg IV /od
Tab. Lasix 40mg bd
Tab. Aldactone 50mg bd
Tab.pantop 40 mg od
Tab. Udiliv 300mg bd
Syrup. Lactulose 15ml od
Daily weight and abd girth monitoring.
DAY-2:
Fluid(<1l/day) and salt(<2g/day) restriction.
Inj.vit k 10mg IV /od
Tab. Lasix 40mg bd
Tab. Aldactone 50mg bd
Tab.pantop 40 mg od
Tab. Udiliv 300mg bd
Syrup. Lactulose 15ml od
Tab. Benfomet plus od
Daily weight and abd girth monitoring.
ADVISE AT DISCHARGE:
Fluid(<1l/day) and salt(<2g/day) restriction.
Tab. Lasix 40 mg bd
Tab. Aldactone 50 mg bd
Tab. Pantop 40mg od
Tab. Udiliv 300mg bd
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