General medicine case-8

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Date of admission: 20/11/2021

A 48 year old male who is farmer by occupation came to the OPD with chief complaints of bilateral pedal edema and pain in the abdomen since 20 days.

History of present illness:

The patient was apparently asymptomatic 10 years back when he started developing depression and was addicted to alcohol.

9 years back he made a suicide attempt by consuming poison for which he was brought to Kamineni and treated. An year later he again made a suicide attempt where he consumed sleeping pills and he was treated accordingly.

5 years back he had pain in the abdomen following which he was diagnosed with cholelithiasis and laparoscopic cholecystectomy was done.

3 months back, the patient had pain in the abdomen with pedal edema. He was taken to a local hospital and ascitic tapping was done. And 10 days after discharge he again developed ascites and pedal edema, then he was taken to a hospital in Hyderabad where again ascitic tapping was done.

Now the patient is brought to casualty with similar complaints of pedal edema, burning micturition and gross distension of abdomen since 20 days.

History of past illness:

The patient is not a known case of epilepsy, tuberculosis and hypertension.

He is a known case of diabetes since 10 years.

Personal history:

- The patient has no loss of appetite

- He takes mixed diet

- No sleep disturbances

- The patient consumes alcohol everyday.

Family history:

There are no similar complaints in the family.

Treatment history: 

The patient is not allergic to any known drugs.

General examination:

The patient is conscious, coherent, uncooperative at the time of examination.

- No Pallor 

- No icterus

- No cyanosis

- No clubbing of fingers and toes

- No lymphadenopathy

- Bilateral pedal edema is present 

Vitals : temperature - afebrile

              Pulse rate - 90 beats/ min

              Respiratory rate - 20 cycles per min

              BP - 130/90 mmHg

Systemic examination : 

CVS:

Inspection - chest wall is bilaterally symmetrical

No precordial bulge 

- No visible pulsations, engorged veins, scars, sinuses

Palpation - JVP is normal

Auscultation - S1 and S2 heard

RESPIRATORY SYSTEM

- Position of trachea is central 

- Bilateral air entry is normal

- Normal vesicular breath sounds heard

- No added sounds

PER ABDOMEN :

Shape of the abdomen: distended

- abdomen is not tender

- bowel and bladder sounds heard

- no palpable mass or free fluid

Umbilicus is flat

CNS

- Patient is conscious

- Speech is present

- Reflexes are normal

Investigations: 

20/11/2021:

Rapid test for COVID: negative

BT: 2:30

CT: 5:00

Hb: 8.4 gm/dl

TC: 7000

PCV: 23.8

PLC:1.10

INR: 1.77

Urea:32

S creatinine : 0.7

Na ions: 142

K ions: 3.1

Chloride : 9.8

Ascitic sugar:90

Ascitic protein: 1.2

Ascitic CDC: 150

SAAG:

S albumin : 2.4

Ascitic albumin: 0.5

SAAG: 1.9

Ascitic fluid amylase: 39

Diagnosis:

Cirrhosis of liver

Treatment:

1) TAB LASIX 40 mg PO/ BD

2) TAB ALDACTONE 50 mg OD

3) PROTEIN- X POWDER 2 Scoops in 100 ml milk

BD

4) BP, PR, TEMPERATURE MONITORING 4th hourly

5) INJ. THIAMINE 1 amp in 100 ml NS IV/ OD

6) INJ. OPTINEURON 1 amp in 100 ml NS IV/OD

7) DAILY BODY WEIGHT AND ABDOMINAL GIRTH MONITORING

8) STRICT I/O CHARTING

9) FLUID RESTRICTION (< 1.5 L/ day) and SALT RESTRICTION (<2.4 g/ day)

1) How does poisoning affect liver?

2) Is there a role of sleeping pills in causing liver damage?