A 45 year old male with bilateral pedal edema and abdominal distention
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Case presentation :
A 32 year old man who works as an auto driver presented with the 2 months history of cough with mild expectoration ,H/o loss of weight and appetite for 2months ,he also reported 1week H/o progressive dyspnoe associated with pedal edema. The pt was in his usual state of health 2months ago then 2 he insidiously developed cough associated with spoon full of whitish mucouid expectoration only in the morning ,the cough is often dry and irritable and is maximal on waking up in the morning at 6 am. His cough has not progresses over the past 2 months. No H/o worsening with meals,It is not associated with wheezing or chest pain. There is no seasonal variation. It is most troublesome early in the mrng, he reports that it subsides as the day progresses. No h/o chestpain or wheezing He expectorates only a spoonful of sputum which is whitish and seromucinous, he doesn't have worsening of cough or expectoration while change in posture. There is no h/o expectoration of Frank blood or blood streaks on sputum. The sputum is not foul smelling and there are no plugs, casts or any granules in his sputum. The Pt also reported with h/o loss of appetite and involuntary loss of weight since 2months. His LOA is not associated with fear of eating or any abnormal desire for unsual food. He denies any H/o emotional upset or any traumatic event in the recent past. He doesn't not have any unusual pigmentation of skin(addisons) The Pt admits chronic h/o alcolism and he says that he frequently skips meals after taking alcohol. The is no h/o homeless ness or lack of availability of food. No h/o any drug There is no h/o any self induced vomiting or drug abuse. His loa is associated with involuntary loss of wt which is detected by loosening of his clothes which use to fit well previously. He doesn't have any difficulty in swallowing. He has no h/o vomiting and diarrhea in the recent past. No h/o belching to any type of food. No h/o pain abdomen. He doesn't have regurgitation, dyspepsia or any altered bowel habits in the recent past. The pt doesn't report any h/o fever, night sweats, wheezing, chest pain, hemoptysis, or any palpitations. He developed gradually progressive dyspnea since 1wk which quickly progressed from grade 1 to 3 over 1wk. Dyspnea is exertional and not associated with pnd or orthopnea. Dyspnea is relieved with rest and has no positional or diurnal variation. The pt also reported a day h/o pedal edema which started gradually in his feet ascended upto his ankles at which point he presented to us. No h/o decreased urine output, jaundice, facial puffiness. No h/0 palpitations, syncope. Pt reports being fatigue past 1wk. H/o fatigue is most troublesome in late afternoon and evening which relieves with rest. He doesn't have any h/o altered sleep habits. Poor self care, feeling low or anxious or any suicidal ideas. ">Past history : no similar complaints in the past
H/o TB 3 years back ,used ATT for 6months and stopped.
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PERSONAL HISTORY:
He was on mixed diet, decreased appetite, bowel habits normal
H/o alcohol intake180 ml
GENERAL EXAMINATION: pt is conscious, coherent, cooperative and oriented to time, place and person
His hair appears thin and grey. The pt has temporal wasting on both sides. He doesn't have obvious nasal deformities. Tongue and oral cavity appear normal. He has grade 1 clubbing with obliteration of schwamorths angle. nail fluctuation is positive . No lymphadenopathy. He doesn't have any skin or mucosal rashes, limb deformities, spinal deformities. no pallor ,icterus,cyanosis
There is pedal edema of both legs.
VITALS:
Temperature-99.8°f on presentation
BP:130/60mmhg
PULSE:79pm
RR:24cpm
Spo2:98%
GRBS:103mg/dl
CVS:s1 s2 heard,no murmurs
Rs : Size : upper zone -77 –80.5cms Lower zone :76–79cms AP:17cms,transverse :25cms Intercoastal retraction : normal in lower and anterior lower 3rd No use of accessory muscles Apical impulse is not visible Diaphragm movement normal, bilateral limitation of expansion No scars and sinuses Palpation : all inspectory findings are confirmed Repiratory movement : Right. Left Upperzone. Dec. Dec Middlezone N. N Lowerzone. N. Dec Position of trachea - central Tactile local fremitus: Right. Left Upper anterior N. Dec Posterior N. Inc Mid. N. N Lower. N. N No localized swelling, tenderness No palpable rales,rhonci No palpable lymph nodes Valsalva and Muller's maneuver : Rt. Lt Valsalva. N. N Muller's. N. No retraction lPercussion : Rt. Lt Anterior supraclavicular R impaired Clavicular. N. N Infra. R. R Mammary R. R Lateral Axillary. R. R Infraaxillary. R. R Posterior Suprascapular. impaired. impaired Scapular. R. R Interscapular R. R Infrascapular R. b R /p>
P/A: soft.non tender
CNS: Higher mental function normal
Cranial nerves intact
Motor system: intact
Sensory system: intact
But power decreased in both hamstrings .
Day 1 :
Treatment :
1)fluid restriction less than 1.5lts/ day
2)salt restriction less than 4gms / day
3) inj lasix 40mg Iv BD if bp more than 110/80 mmhg
4) inj optineuron 1amp IM /OD
5) daily 1 egg white
6) syrup cremaffin plus 15 ml H/S
7) tab Benofomet plus OD
8) daily wt monitoring
9)Bp ,PR,temp,spo2 monitoring 4th hourly
10)tab digoxin 0.25mg po /od
11)T.Dytor plus po od
Day 2 :
Treatment :
1)fluid restriction less than 1.5lts/ day
2)salt restriction less than 4gms / day
3) inj optineuron 1amp IM /OD
4) daily 1 egg white
5) syrup cremaffin plus 15 ml H/S
6) tab Benofomet plus OD
7) daily wt monitoring
8)Bp ,PR,temp,spo2 monitoring 4th hourly
9)tab digoxin 0.25mg po /od
10) T.Dytor plus po od
Day 3 :
No fresh complaints
Treatment :
1)fluid restriction less than 1.5lts/ day
2)salt restriction less than 4gms / day
3) inj optineuron 1amp IM /OD
4) daily 1 egg white
5) syrup cremaffin plus 15 ml H/S
6) tab Benofomet plus OD
7) daily wt monitoring
8)Bp ,PR,temp,spo2 monitoring 4th hourly
9)tab digoxin 0.25mg po /od
10) T.Dytor plus po od
11) Tab pan 40mg OD
Diagnosis : pulmlnary tb(right and legt upper lobe bronchiectasis) with alocholic hepatitis with alcoholic polyneuropathy
