45 year old male with Abdominal distension and pedal edema.

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CASE:-

45 year old male complaints of abdominal distension and b/l pedal edema (pitting type) , shortness of breath and scrotal swelling.

CHIEF COMPLAINTS:-

Patient complaints of 

•Abdominal distension 

•B/l pedal edema 

•Shortness of breath 

•scrotal swelling 

  Since 25 days 

HISTORY OF PRESENTING ILLNESS:-

Patient was apparently asymptomatic 6 years ago, then he had swellings over chest for which he went to hospital and was diagnosed as diabetic and was on medication since then.

•2 years ago when he went for routine checkup he was diagnosed as hypertensive and was on medication .

•6 months back patient's speech was reduced for which he went to a local hospital where he was found to have low GRBS (27 mg/d) and he

also had jaundice and was advised to stop consuming alcohol. 

•25days back he developed scrotal swelling, pedal edema, abdominal distension which was insidious in onset and gradually progressive, he also exhibited shortness of breath, for which he went to an RMP and was referred to KIMS, Narketpally.

PAST HISTORY:-

*H/O DM since 6 years and used tab.glibenclamide 5mg+ metformin 500mg, stopped taking medication since 6 months *H/O HTN since 2 years and taken Tab. Telma 40mg.

FAMILY HISTORY:- Insignificant.

PERSONAL HISTORY:-

•Diet:- mixed 

•Appetite:- normal 

•Sleep:- adequate 8 hrs per day

•Bowel and bladder :- regular

•Addictions:- ☆chronic alcoholic since 20years

                           -360 ml per day, stopped drinking since 1 month.

                       ☆ Chronic smoker since 30 years - 2 packs per day .

•Occupational history:-hotel owner 

GENERAL EXAMINATION:-

Patient is conscious, coherent and cooperative well oriented to time, place and person. 

•Height:-158cm  

•Abdominal girth: 124cm 

VITALS:-

•Temp: afebrile 

•Pulse rate: 90bpm

•Respiratory rate: 22

•BP: 130/80

•SpO2:98

Pallor, cyanosis, clubbing, are absent 

Edema-pedal( pitting)

Icterus present .

SYSTEMIC EXAMINATION:-

●ABDOMINAL EXAMINATION:-

☆Inspection: 

          Abdominal distended

          Umbilicus everted 

          Engorged veins present 

          No visible peristalsis 

          No scars , sinuses .

☆Palpitation:

          Soft non-tender 

           no hepatomegaly or splenomegaly 

           

☆Percussion : Shifting dullness 

☆ Auscultation:- Bowel sounds heard.

● CVS :- s1,s2, heard , no murmurs present.

●RESPIRATORY SYSTEM:- Normal vesicular breath sounds heard.

● CNS:- No focal neurological deficit seen.

Investigations.... 

Ecg.... 

Chest xray 

2D echo

PROVISIONAL DIAGNOSIS:- 

Chronic liver disease  with portal hypertension .

TREATMENT: -

1.Tab Lasix 80 mg po OD 

2.Tab Aldactone  50mg BD

3.Tab Lactulose 20ml ODHS