57 year ol man with jaundice ,pedal edema and abdominal distension since 3 years and bleeding gums since 3 days

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Here is a case i have seen:

A 30 year old male came with
C/o shortness of breath(grade2)according to NYHA since 1month
c/o palpitataions since 1 month
C/o fatigue since 1month
C/o body pains since 1month
Pt was apparently asymptomatic 1month back then developed shortness of breath which was gradual in onset ,progressive associated with palpitations grade 2 according to NYHA associated with orthopnea,no c/o sweating ,vomitings
C/o bodypains since 1 month (diffuse type of pain)
H/o of fever 1 month for which he went to an rmp,later on medications subsided .
H/o herbal medication taken for jaundice 1 month back
H/o weight loss since 1 month
No c/o cold,cough,vomitings,burning mictuaration, pedal edema,melena,giddiness,headache,
constipation
H/o RTA (3 years back ) had right leg fracture and had implant for right leg
Not k/c/o DM,HTN
personal:
Pt has mixed diet
No loss of apetite
Bowel and bladder movements normal
H/o smoking since 4 years (1 pack /day)
H/o alcohol (SAARA)since 7 years 

O/e:Pt is c/c/c

Palor present

No icterus, cynosis, clubbing,Lymphaenopathy, pedal edema 

Afebrile to touch 

Bp:130/80

Pr:90

Cvs:s1s2 heard

Rs:nvbs

P/a:soft,non tender

Cns:pt is c/c/c

Higher mental functions -N

Motor system -N

Sensory 

Cerebellum-N

LFT:

TB : 0.94

DB : 0.20

AST : 62

ALT : 10

ALP : 110

TP : 6.3

albumin : 4.0

A/G : 1.78

Rft-

Na : 139

K : 3.8

Cl : 103

Sr. Creat : 0.7

Blood urea : 14

CBP:

Hb : 3.1

TLC : 3,500

PLT : 60,000

Sr. Iron : 65ug/dl

Ferritin -417ng/dl

LDH : 2271

Serology :negative

Hemogram at 10:00 pm 

Hb : 2.5

TLC : 2,900

PLT : 40,000

BGT- B+

ECG

Treatment:

1.inj vit B12 1000mcg /im/daily for 1 week

2.tab vit c od

3.restrict iv fluids 

4.tab pcm 500mg po/sos

5.temperature monitoring

6.BP/PR/SPO2 hrly

Day1:

O/e: Pt is c/c/c

C/o sob since 1month 

Palpitations +

Body pains and fatigue since 1 month

Palor present

No icterus, cynosis, clubbing,Lymphaenopathy, pedal edema 

Afebrile to touch -98.9f

Grbs-95mg/dl

Bp:120/80 mmhg

Pr:90 bpm

Cvs:s1s2 heard

Rs:nvbs

P/a:soft,non tender

Cns:pt is c/c/c

Higher mental functions -N

Motor system -N

Sensory -N

Cerebellum-N

Investigations:

ESR-150

Peripheral smear:

Reticulocyte count:0.5

Thyroid 

T3 -  0.80

T4-   9.56

TSH-1.07

USG ABDOMEN:

2decho

Treatment:

1.inj vit B12 1000mcg /im/daily for 1 week

2.tab vit c od

3.restrict iv fluids 

4.tab pcm 500mg po/sos

5.temperature monitoring

6.BP/PR/SPO2 hrly

Day3:

O/e: Pt is c/c/c

C/o sob (grade2 )

Palpitations +

No fever spikes

Palor present

No icterus, cynosis, clubbing,Lymphaenopathy,

pedal edema present

Afebrile to touch -98.9f

Bp:120/80 mmhg

Pr:90 bpm

Cvs:s1s2 heard

        Loud S2 in all areas 

         ESM - pulmonary area 

        Carotid brue           -   +

        Parasternal heave - +

Rs:NVBS

P/a:soft,non tender

Cns:NAD

Cerebellum-N

Investigations:

Treatment:

1.inj vit B12 1000mcg /im/daily for 1 week

2.tab vit c od

3.restrict iv fluids (<1.5 lit/day)

   Salt restriction (<2 g/day)

4.tab pcm 500mg po/bd

5.tab lasix 20mg od/po

6.temperature monitoring 4th hrly

7.BP/PR/SPO2 12th hourly

8.one prbc transfused i/v/o hb-2.3

Day4:

O/e: Pt is c/c/c

C/o sob (grade2 )

Palpitations +

No fever spikes

Palor present

No icterus, cynosis, clubbing,Lymphaenopathy,

pedal edema present

Afebrile to touch -98.9f

Bp:110/60 mmhg

Pr:88 bpm

Cvs:s1s2 heard

        Loud S2 in all areas

  Rs:NVBS

P/a:soft,non tender

Cns:higher mental functions intact

Motor - N

Sensory - vibration decreased on lower limbs

Cerebellum-N

Investigations:

Widal - negative 

Dengue - negative 

Treatment:

1.inj vit B12 1000mcg /im/daily for 1 week(day 3)

2.tab vit c od

3.restrict iv fluids (<1.5 lit/day)

   Salt restriction (<2 g/day)

4.tab pcm 500mg po/bd

5.tab lasix 20mg od/po

6.inj pantop 40mg /iv/od

7.temperature monitoring 4th hrly

8.BP/PR/SPO2 12th hourly

Day5:

O/e: Pt is c/c/c

C/o - loose stools of 2 episodes 

         Sob decreased compared to day of                             admission

Palpitations +

No fever spikes

Palor present

No icterus, cynosis, clubbing,Lymphaenopathy,

pedal edema present

Afebrile to touch -98.9f

Bp:100/70 mmhg

Pr:94 bpm

Cvs:s1s2 heard

        Loud S2 in all areas

  Rs:NVBS

P/a:soft,non tender

Cns:NAD

Investigations:

Treatment:

1.inj vit B12 1000mcg /im/daily for 1 week(day 4)

2.tab vit c od

3.restrict iv fluids (<1.5 lit/day)

   Salt restriction (<2 g/day)

4.tab pcm 500mg po/bd

5.tab lasix 20mg od/po

6.inj pantop 40mg /iv/od

7.ORS sachet in 1 litre of water

8.temperature monitoring 4th hrly

9.BP/PR/SPO2 12th hourly

Day 6:

O/e: Pt is c/c/c

C/o - loose stools of 4 episodes 

         Sob decreased compared to day of                             admission

Palpitations +

No fever spikes

Palor present

No icterus, cynosis, clubbing,Lymphaenopathy,

pedal edema present

Afebrile to touch -98.6 F

Grbs-116 mg/dl

Bp:120/80 mmhg

Pr:84bpm

Cvs:s1s2 heard

        Loud S2 in all areas

  Rs:NVBS

P/a:soft,non tender

Cns:NAD

Investigations:

Treatment:

1.inj vit B12 1000mcg /im/daily for 1 week(day 4)

2.tab vit c od

3.restrict iv fluids (<1.5 lit/day)

   Salt restriction (<2 g/day)

4.tab pcm 500mg po/bd

5.tab lasix 20mg od/po

6.inj pantop 40mg /iv/od

7.ORS sachet in 1 litre of water

8.tab sporolac po/od

9.temperature monitoring 4th hrly

10.BP/PR/SPO2 12th hourly