30 YEAR OLD MALE WITH PEDAL EDEMA
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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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