A 35 year old man presented to the casualty with the complaints of 
Bilateral pedal edema since 1 week
Dyspnea since 15 days 
Abdominal distension since 2 months 

History of Presenting illness

A 35 year old man, who sells plants  at nalgonda tells us a detailed insight to the reason for all his problems. He says he has been married 9 years back but since the past 5 years he has been living apart from his wife and his 2 sons due to marital issues. Prior to that he used to consume alcohol occasionally but since the past 5 years he has been consuming about half to 1 bottle of whiskey everyday.
3 years back, he paid a visit to a local hospital with abdominal distension and pedal edema and he was diagnosed with chronic liver disease for which he used medications for a while and stopped. He was even diagnosed to be a diabetic back then and he started using Tab Metformin 500mg OD.
2 months back, his abdominal distension increased and his eyes became yellow after which he started using local herbal medications. 
Since the past 15 days he has been experiencing dyspnea on exertion after which he paid a visit to a local hospital and they put him on certain medications which relieved his symptoms. 
Since the past 1 week, he says his abdominal distension has increased and so as his dyspnea, it has increased to such a point that even at rest it isn't getting relieved. 
On presentation to casualty,
He was tachypneic with icterus and a respiratory rate of 36 cpm,
Heart rate of 120 bpm, BP at 130/70mmhg and GRBS 150mg/dl
Cvs - JVP raised
Muffled S1,S2+
Lungs - Inspiratory crepts in bilateral IAA,SA 
Per Abdomen  - Distended
Bowel sounds +
Past illness
K/C/O type2DM since 2 years on tab mentformin 500mg
No History of hypertension, TB,Asthma
Personal history:
Diet:Mixed
Appetite:Normal
Sleep:Regular
Bowel and bladder:Regular
Addictions:The Patient has a history of alcohol intake that began 10 years ago and has been drinking 180ml of whiskey 
Drug history:
On oral hypoglycemic for DM2 for 2 years(Metformin 500mg)
Family history:
No Similar Complaints in the family

General Examination:
 was examined in a well-lit room, with informed consent.
Conscious and coherent and cooperative,Orienteted to time,person and place
Pallor:Absent 
Icterus:Present
Cyanosis:absent
Clubbing:absent
Lymphadenopathy:absent
Edema:present(pitting type)
Vitals(at the time of admission):

Temperature:98.4F
PR:P8Bpm
RR:24cycles/min
BP:110/80 mm of hg
SpO2:96%
GRBS:155mg%

Systemic examination:
CVS:S1,S2 heard
Respiratory system:
  Dyspnea present
   Vesicular breath sounds heard
Per abdomen: distended  
   Tenderness:epigastric region
    Free fluid: present
CNS:Normal


Investigations:
ECG:
18/01/22

20/01/22:

2D ECHO:



FBS:


Blood Urea:


S.Creatinine 

APTT:

Bleeding time and clotting time:

S.Electrolytes:

Prothrombin time:

LFT:


Ultrasound


Provisional diagnosis:
Diagnosis-
1. DCMP with EF 20% secondary to alcoholism 
2. Chronic Liver disease 
3. Alcohol dependence syndrome
4. Known case of Type 2 DM since 2 years

Treatmennt:

19/01/22
1)Head end elevation
2)O2 supplementation(maintain Spo2>92%)
3)INJ.PANTOP 40mg iv/OD
4)TAB.UDILIV 300mg PO/BD
5)INJ.THIAMINE 20amp in 100ml NS/IV/TID
6)SYP.LACTULOSE 10ml/PO/TID
7)Maintain 2-3 stools per day
8)Fluid restriction <1liter/day
9)GRBS Charting 6th hourly
10)TAB.LASILACTONE(20/50)MG PO/BD
11)TAB.PREGABA 75 mg/PO/OD
12)NICOGUMS 2mg SOS
13)INJ.HUMAN ACTRAPID INSULIN S/C(8Am-2pm-8Pm)
14)Salt restriction <2gms/day




20/01/22
1)Head end elevation
2)O2 supplementation(maintain Spo2>92%)
3)INJ.PANTOP 40mg iv/OD
4)TAB.UDILIV 300mg PO/BD
5)INJ.THIAMINE 20amp in 100ml NS/IV/TID
6)SYP.LACTULOSE 10ml/PO/TID
7)Maintain 2-3 stools per day
8)Fluid restriction <1liter/day
9)GRBS Charting 6th hourly
10)TAB.LASILACTONE(20/50)MG PO/BD
11)TAB.PREGABA 75 mg/PO/OD
12)NICOGUMS 2mg SOS
13)INJ.HUMAN ACTRAPID INSULIN S/C(8Am-2pm-8Pm)
14)Salt restriction <2gms/day
15)TAB.MET XL 12.5mg/PO/BD

20/01/22:
1)Head end elevation
2)O2 supplementation(maintain Spo2>92%)
3)INJ.PANTOP 40mg iv/OD
4)TAB.UDILIV 300mg PO/BD
5)INJ.THIAMINE 20amp in 100ml NS/IV/TID
6)TAB.ALDACTONE 50mg PO/BD
7)Maintain 2-3 stools per day
8)Fluid restriction <1liter/day
9)GRBS Charting 6th hourly
10)TAB.LASILACTONE(20/50)MG PO/BD
11)TAB.PREGABA 75 mg/PO/OD
12)NICOGUMS 2mg SOS
13)INJ.HUMAN ACTRAPID INSULIN S/C(8Am-2pm-8Pm)
14)Salt restriction <2gms/day
15)TAB.MET XL 12.5mg/PO/BD
16)TAB.DYTOR 20mg/PO/OD

21/01/22:
1)Head end elevation
2)O2 supplementation(maintain Spo2>92%)
3)INJ.PANTOP 40mg iv/OD
4)INJ.THIAMINE 20amp in 100ml NS/IV/TID
5)TAB.ALDACTONE 50mg PO/BD
6)Maintain 2-3 stools per day
7)Fluid restriction <1liter/day
8)GRBS Charting 6th hourly
9)TAB.LASILACTONE(20/50)MG PO/BD
10)TAB.PREGABA 75 mg/PO/OD
11)NICOGUMS 2mg SOS
12)INJ.HUMAN ACTRAPID INSULIN S/C(8Am-2pm-8Pm)
13)Salt restriction <2gms/day
14)TAB.MET XL 12.5mg/PO/BD
15)TAB.DYTOR 20mg/PO/OD

Advise at discharge

1. Tab Dytor 20mg PO/OD 
To be taken at 8am 
2. Tab Met XL 12.5/PO/BD
To be taken at 8am and 8pm
3. Tab Aldactone 50mg/PO/BD
8am and 8pm 
4. Tab Metformin 500mg/PO/OD at 8 am
5. Tab Pantop 40mg/PO/OD/BBF
At 8am
6. Tab Thiamine 100mg/PO/BD
7. Nicogums 2mg/PO/BD at 8am and 2pm and sos
8. Syrup Lactulose 10ml/PO/BD 
9. Advised fluid restriction <1/day
Salt restriction <2g/day 

Review after 1 week to General Medicine and Psychiatry OPD


2decho findings:
1. Global Akinetic with severe TR, Mild AE and Mild PR, Moderate MR
2. All chambers dilated with EF 20%
3. Mild to moderate PE
4. Severe LV dysfunction



Popular posts from this blog

Image
54 YEAR OLD MALE PATIENT WITH DISTENTION OF ABDOMEN, JAUNDICE, BURNING MICTURITION SINCE 15 DAYS   This is an online E Logbook to discuss our patient's de-identified health data shared after taking his/her guardian's signed informed consent. Here, we discuss our individual patient's problems through a series of inputs from an available global online community of experts to solve those patients' clinical problems with collective current best evidence-based inputs. This e-log book also reflects my patient-centered online learning portfolio and your valuable inputs in the comment box are welcome. —————————————————————————————————————————————- A 54 YEAR OLD MALE  PATIENT CAME WITH COMPLAINTS OF  1. DISTENSION OF ABDOMEN SINCE 15 DAYS 2. H/O JAUNDICE SINCE 15 DAYS 3.BURNING MICTURITION SINCE 15 DAYS NO H/O FEVER,SOB,PEDAL EDEMA HOPI:  PATIENT WAS APPARENTLY ASYMPTOMATIC 5 MONTHS BACK, ON JAN 2021 PATIENT WAS OPERATED FOR GALL STONES.POST OP NO COMPLICATIONS AND WAS NORMAL .
Read more
Image
62 year old male with loss of appetite,sob and fever   CBBLE UDHC similar cases  THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT  62 year male farmer by occupation came with complaints of loss of appetite since 20 days ,sob and fever, since 20 days. Vomiting since 2 days. ,Painful swelling in the left  gluteal region since 2 days and pain in the right hip region HOPI : patient was apparently asymptomatic 20 days back then he went to outside private hospital with complaints of fever and sob and on investigation his creatinine 5.3 ,so sent for hemodialysis to our hospital. C/o shortness of breath since 20 days  grade 4 ,no pnd and no orthopnea Fever treated at
Read more
A 35 YR OLD MALE PATIENT WITH DKA This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent.Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input. This E-blog also reflects my patient's centred online learning portfolio. I have been given this case to solve in an attempt to understand the topic of "Patient Clinical Data Analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan. Complaints of shortness of breath since two days on and off increased since morning  complains of fever since two days  complains of burning micturition since two days HOPI Patient was apparently a symptomatic five years back then he was diagnosed
Read more