28 year old male with SOB and ABDOMINAL DISTENSION

 A 28 year old male came to OPD with chief complaints of 

  • Abdominal distention since 20 days 

  • Shortness of breath since 15 days  


History of present illness 


Patient was apparently asyptomatic 4 months back then In April he had fever , yellowish discoloration of sclera for 3 days , fever is not associated with chills and rigor ,no evening rise of temperature then he went to hospital , used medication for 1week. 

Symptoms subsided after a week ,then again he started to consume alcohol(180 ml) daily.


In the month of June he had fever, Abdominal distension, yellowish decolorisation of sclera , went to a hospital in jangaon took ayurvedic medicine for 1 week , symptoms got subsided. 


After that he again started to drink alcohol from July. 

Then he presented to opd on July 28 with complains of Abdominal distension since 6days, Shortness of Breath of Grade lll ,fever was not associated with Chills and rigor without evening rise of temperature, he had altered sleep cycle, facial puffiness, pedal edema is seen for 3 days. 

On 29/7/22

Ascitic tap was done. 

He came back to OPD  on 22/8/22 with abdominal distention since 20 days which got  increased on consuming food and decreased by passing stools.


He also complains of shortness of breath since 15 days even while he was taking resting which was  associated with palpitations , giddiness.


He developed dry cough since 5 days that relived on medication 


He complains a fever  2 days ago that got relived on medication 


He complains of loss of appetite since 2 days due to abdominal tightness 


Past history 


N/K/C/O DM,HTN,TB,ASTHMA,CAD 


DAILY ROUTINE : 

He is a Daily  labourer (construction worker) by occupation.

Wakes up at 6Am 

Drinks tea 

Goes to work at 8 AM 

 Breakfast at 9AM 

 Lunch  at 12 PM

 Eats snacks in the evening along with alcohol.

Dinner at 8 PM

Sleeps 


PERSONAL HISTORY: 


Diet : Mixed  


Appetite : Decreased  


Sleep : Disturbed 


Bowel and Bladder moments : Constipated


Micturition : Normal  


Addictions : Chronic alcoholic and smoker 

                       He consumes 180 ml of alcohol                          daily

                      Smokes one packet of  cigarettes/

                      beedi per day 

                      He chews gutka, tobacco 


FAMILY HISTORY: 


Not significant  


General physical examination: 


Patient is conscious ,coherent and cooperative and well oriented to time, place and person. 

moderately built and nourished. 


Pallor-absent 


Icterus-present 


Cyanosis-absent 


Clubbing-absent 


Lymphadenopathy-absent 


Edema-absent 


Skin had petechial spots  


Vitals:


Temperature - 98.2*c 


PR :- 95bpm 


RR :-22cpm 


BP :- 130/80mm Hg 


SPO2 :- 98% 


GRBS :- 167mg/dl.



Systemic examination: 


CNS - NAD 


CVS- S1 S2 heard ,no murmurs 


RS-BVS+, wheeze+ 


P/A-soft ,Uniformly distended,Engorged veins present.


CLINICAL IMAGES 







Investigations 











Provisional diagnosis

Chronic liver failure 



TREATMENT:



1. FLUID RESTRICTION. 


2. SALT RESTRICTED NORMAL DIET. 


3. INJ. CEFOTAXIM 2 GRAM TWICE DAILY INTRAVENOUSLY. 


4. INJ. VIT K 1 AMP IN 100 ML NS ONCE DAILY INTRAVENOUSLY. 


5. INJ. THIAMINE 1 AMP IN 100 ML NS ONCE DAILY INTRAVENOUSLY. 


6. INJ. PAN 40 MG TWICE DAILY INTRAVENOUSLY. 


7. INJ. ZOFER 4 MG THRICE DAILY INTRAVENOUSLY. 


8. TAB. PCM 650 mg SOS (<1 GRAM / DAY). 


9. SYP. LACTULOSE 15 ML 30 MINUTES BEFORE FOOD THRICE DAILY.


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