27 years male with CLD

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I've been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.

CASE:

27 years old male , resident of nalgonda,came to OPD with chief complaints of loss of appetite since 20 days

Complains of tremors since 15 days

Complains of blood in urine since 10 days

Complains of pedal edema since 10 days

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 20 days back then he had loss of appetite for which he went to hospital and diagnosed as CLD, splenomegaly with portal hypertension and took medication. After which he complains of hematuria since 10 days and pedal edema which is pitting type, relieved on taking rest and aggravated on walking. Has tremors since 15 days. Malena positive 20 days back for 10 days.

No abdominal pain, no vomitings, no burning micturition, no loose stools.

PAST HISTORY

H/O surgery appendectomy

N/k/c/o HTN,DM, TB,CVD, thyroid disorders ,epilepsy.

PERSONAL HISTORY:

Diet - mixed

Appetite - increased

Sleep -adequate

Bowel and bladder movements - regular

Addictions- Alcohol consumption since 7 years, whisky (500ml) daily.

DAILY ROUTINE:

4am- wake up