GENERAL MEDICINE : A 46 year old male

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A 46 year old male who is resident of Bhongir and by occupation a Barber came to OPD on 11th of January at 4:10 pm.

CHIEF COMPLAINTS :-

A 46 year old male complaints of :-

- Intermittent fever since 12 days

- Loss of appetite since 12 days

- Pedal edema since 7 days

- Shortness of breath since 7 days

- Jaundice since 7 days

HISTORY OF PRESENT ILLNESS :-

Patient was apparently asymptomatic 12 days back.Then he complained of fever which is low grade, intermittent, on and off episodes and get relieved on medication. 

Patient c/o B/L pedal edema present below the knees, pitting type, present since 7days.It was aggravated on standing for long periods and slightly reduced on taking rest. 

Shortness of breath since 7 days which is grade 2 (developing shortness of breath while walking). 

Patient also c/o loss of appetite since 12 days. 

Patient also c/o abdominal tightness and bloating of abdomen. 

No History of chest pain, chest tightness, palpitations. 

No History of abdominal pain, vomitings, constipation, loose stools. 

No History of burning micturition, decreased urine output. 

No Head ache, Giddiness, Confusion. 

HISTORY OF PAST ILLNESS:-

K/C/O Hypertension since 3 years on unknown medication.

No h/o DM,TB, CAD, Asthma, Epilepsy.

PERSONAL HISTORY:-

Diet - Mixed

Appetite - Normal(Decreased since 12 days) 

Bowel and Bladder movements - Regular

Addictions - patient consumes alcohol since 25 years (90ml per day)

Tobacco chewing since 5 years. 

FAMILY HISTORY :-

No relevant family history. 

GENERAL EXAMINATION:-

Patient is conscious, coherent and cooperative and well oriented to time, place and person.
Moderately built and well nourished.
 
Pallor: yes
Icterus: yes
Cyanosis: no
Clubbing of fingers: no
Lymphadenopathy: no
Pedal oedema: yes

VITALS:-
Temperature - Afebrile
BP - 110/70mmHg 
Pulse Rate - 100bpm
Respiratory Rate - 16 cpm
SpO2 - 98%

CLINICAL IMAGES :-
SYSTEMIC EXAMINATION:-

CNS examination:

-Patient is conscious, coherent and cooperative.
-Speech is normal.
-NAD(no abnormality detected)

CVS examination:

-S1, S2 are heard.
-No murmurs.


Respiratory system examination:

-Bilateral air entry present.
-Normal vesicular breath sounds heard.
-Position of trachea central.


Abdomen:
Inspection:
Shape of Abdomen:Distended
No Dilated veins, visible peristalsis, engorged veins, scars.
Palpation:
Liver : palpable 
Spleen: not palpable
Percussion:
Resonant note heard
Auscultation:
Bowel sounds heard. 

PROVISIONAL DIAGNOSIS :-
Chronic liver disease

INVESTIGATIONS :-
ECG :-
HEMOGRAM :-
RANDOM BLOOD SUGAR :-BLOOD GROUPING :-BLEEDING AND CLOTTING TIME :-
Urea - 17
Creatinine - 0.6
Na+ - 139
K+ - 4.0
Cl - 103
DB - 18.08
Tb - 19.61

TREATMENT :-

-Inj Monocef 1gm IV/BD
-Inj Neomol 1gm IV
-Syrup Lactulose 30ml PO/BD
-Inj Lasix 20mg IV/BD
-Inj Thiamine 100mg 
-Tab Rifagut 550mg
-Tab Udiliv 300mg
-Metadoxine

FINAL DIAGNOSIS :-

Decompensated Chronic Liver Disease
Moderate anemia


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