A 60 YR old male pt. with decreased urine output


Case History and Clinical Findings
PATIENT CAME WITH C/O ABDOMINAL DISTENSION ,DECREASED URINE OUTPUT ,
SWELLING OF B/L LOWER LIMBS SINCE 4 MONTHS.
C/O SOB ON EXERTION -GRADE 3 ON MMRC.
C/O DECREASED APPETITE SINCE 2 MONTHS.
C/O CONSTIPATION SINCE 1 MONTH ,PASSING STOOLS ON EVERY 3RD DAY.
C/O BURNING MICTURITION SINCE 1 MONTH
C/O FEVER SINCE 10DAYS
C/O COUGH WITH EXPECTORATION SINCE 4 -5 DAYS ASSOCIATED WITH WHITIS MUCOID
SPUTUM NOT BLOOD TINGED.
HOPI:
PATIENT WAS APPARENTLY ASYMPTOMATIC NORMAL 4 MONTHS BACK . HE THEN
DEVELOPED ABDOMINAL DISTENSION WHICH IS INCIDIOUS IN ONSET AND GRADUALLY
PROGRESSIVE ,ASSOCIATED WITH PAIN ABDOMEN WHICH IS OF SQUEEZING TYPE IN
UMBLICAL REGION ,AGGRAVATED ON TAKING FOODS .THERE IS SWELLING OF B/L LOWER
LIMBS WHICH IS PITTING TYPE ,EXTENDING UPTO THE KNEE WITH NO AGGRAVTING OR
RELIEVING FACTORS. FEVER IS LOW GRADE ,INTERMITTENT ASSOCIATED WITH
CHILLS,RIGOR AND RELIEVED BY MEDICATION.
NO H/O VOMITINGS,CHESTPAIN,PALPITATIONS,GIDDINESS,SEWATING .
PAST HISTORY:
K/C/O DM T-2 ,HTN SINCE 1 YEAR (UNKNOWN MEDICATION) NOT TAKING SINCE 2 MONTHS.
H/O BLOOD TRANSFUSION 3 MONTHS BACK AND THERE WERE NO REACTIONS
H/O BLOOD TRANSFUSION 1 YEAR BACK ALSO DIAGNOSED WITH PORTAL HYPERTENSION
AND PUT ON CONSERVATIVE MANAGEMENT SINCE 3 YEARS
PERSONAL HISTORY:
DIET : MIXED
CARPENTER BY OCCUPATION
APPETITE. NORMAL
BLADDER AND BOWEL MOVEMENTS: CONSTIPATION
BURNING MICTURITIUON
NO KNOWN ALLERGIES
CHRONIC ALCHOLIC SINCE 35 YEARS STOPPED 2 MONTHS BACK.
K/C/O SMOKER SINCE 30 YEARS
GENERAL AMINATION-NO SIGNS OF PALLOR,CYANOSIS,
ICTERUS,CLUBBING,LYMPHADENOPATHY,EDEMA
VITALS:
HR-104BPM
BP-140/70MM HG
RR-20CPM
CVS-S1 S2 HEARD NO MURMURS
RS-BAE + NO ADDED SOUNDS
P/A SOFT AND NON TENDER.
ON INSPECTION PATIENT HAD ENGORGED VEINS ON ABDOMEN
ON PERCUSIION THERE IS SHIFTING DULLNESS.
CNS-
B/L PUPILS REACTION TO LIGHT
TONE IS 4/5 IN ALL 4 LIMS
REFLEXES
 RIGHT LEFTBICEPS 2+ 2+TRICEPS 2+ 2+SUPINATOR 2+ 2+KNEEJER 2+ 2+ANKLE JERK - -
PLANTAR F FASCITIC TAP DONE ON 8/07/2023-1L ON 10/07/2023-1LBLOOD TRANSFUSION
(PRBC) -1 ON 08/07/2023 PRBC 0N- 10/07/2023 FFP 1 ON-09/07/2023
Investigation
HEMOGRAM:
Diagnosis
CHRONIC LIVER DISEASE SECONDARY TO ALCOHOL [DECOMPENSATED]
K/C/O DMT2 AND HTN SINCE 1 YEAR
?MICROCYTIC HYOOCHROMIC ANEMIASECONDARY TO ? IDA?NUTRITIONAL
Treatment Given(Enter only Generic Name)
TAB NICARDIA 20MG PO/OD STATINJ LASIX 20MG IVINJ ZOFER 4MG IV BDINJ IVF 1 UNIT RL
@50ML/HRINJ PAN 40MG IVBP MONITORING 4TH HOURLYINFORM SOS
Follow Up
REVIEW AFTER 1 WEEK TO GM OPD
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR
ATTEND EMERGENCY DEPARTMENT.

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