A 27 yr old patient with loss of appetite and chronic alcoholic

A 27 yr old patient with loss of appetite and blood in urine came to opd with


CHIEF COMPLAINTS:

Complaints of loss of appetite since 20 days

Complains of tremors since 15 days

Complains of blood in urine since 10 days

Complains of pedal edema since 10 days



HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 20 days back then he had loss of appetite for which he went to hospital and diagnosed as CLD, splenomegaly with portal hypertension and took medication.
 After which he complains of hematuria since 10 days and pedal edema which is pitting type, relieved on taking rest and aggravated on walking. Has tremors 15 days. Malena positive 20 days back for 10 days.

No abdominal pain, no vomitings, no burning micturition, no loose stools. 

PAST HISTORY:
not a known case of HTN,DM, TB,CVD, thyroid disorders epilepsy

H/O surgery appendectomy. 
PERSONAL HISTORY :
Diet: mixed
Appetite: increased
Bowel habits: normal
Bladder habits: normal
Sleep: normal
Addictions:   alcohol consumption 
  Whisky(500ml) daily          

FAMILY HISTORY :
Not significant
GENERAL PHYSICAL EXAMINATION:

Patient is conscious, coherent and cooperative.

Examined after taking valid informed consent in a well enlightened room.

Pallor          - absent
Icterus        - present
 Clubbing    - present
 Lymphadenopathy    - absent
Cyanosis     - absent
Pedal edema  - present
Vitals:
Patient is c/c/c 
Temp:- 97.6  
PR-  95 bpm
BP- 100/60 mmHg
Spo2-95% at room Air 
GRBS-  75mg%
On abdominal examination

Inspection:
Shape of abdomen is scaphoid 
Flanks are free
Umblicus is in position, everted 
Skin is shiny, no scars, no sinuses, no nodules, no puncture marks
No engorged veins
Movements of abdominal wall are normal, no visible gaatric peristalsis 
Palpation: 

Liver examination:

On superficial palpation

No tenderness , pain on palpation 

On deep palpation

No tenderness in liver

Non pulsatile

Spleen examination: 

No tenderness and pain 

Kidney examination:

A tenderness and pain 

On palpation soft and firm in consistency 


Percussion:
Fluid Thrill/Shifting dullness/Puddle’s sign For assessing ascitis

Percussion of Liver for Liver Span-15cm

3. Percussion of Spleen for Splenomegaly – Nixons method, Castell’s method, Barkun’s method of percussion of the Traube’s space

4. Percussion of colonic band of resonance in the presence of Renomegaly

5. Tidal Percussion

Auscultation:

1. Bowel sounds – 10 to 15/min for small bowel, 3 to 5/min for large bowel

2. Bruit – Aortic, Hepatic, Renal Bruit

3. Venous Hum

4. Rub


CVS- S1s2present, no murmurs heard

RS-B/Lair entry present 

       N vesicular breath sounds 

PA- soft,NT

CNS - NAD

PROVISIONAL DIAGNOSIS:

DECOMPENSATED LIVER DISEASE - grade 1 ( hepatic encephalopathy)

HYPOTONIC HYPONATREMIA - diuretic induced 
Investigations:

Treatment:

1. IV FLUIDS NS@ 75

2. Inj VIT K 10mg IV/STAT

3. Inj THIAMINE 200mg IV/BD in 100ml NS 

4. Syp. LACTULOSE 10ml PO/BD 

5. Strict I/O charting 

6. Vitals monitoring - 2nd hourly 





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