30 YEAR OLD MALE WITH PEDAL EDEMA

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23-09-2021
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30 YEAR OLD MALE WITH PEDAL EDEMA 

CASE:
The patient came to the opd with chief complaints of
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 and pain in the abdomen


PAST HISTORY:

H/O of RTA in 2007 which led to leg fracture and he was in a coma for 5 days

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.

4 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 


One month ago:

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


Serology(HbsAg,Hiv,Hcv)- Negative.


PROVISIONAL DIAGNOSIS:

Chronic Liver Disease secondary to alcohol.

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