1601006028 LONG CASE

 

1601006028 LONG CASE- GM

HALL TICKET NO. 1601006028 

General medicine:-LONG CASE

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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: A 55year old male toddy climber by occupation came with complaints of pain abdomen and fever.

Following is my analysis of this patient's problem:

The problems in order of priority I found are 

1) Severe pain abdomen since 10 days

2) Fever since 7days

Chief complaints: 

                            A 55 year old male patient,toddy climber by occupation, resident of miryalguda,came with complaints of 

1)pain abdomen since 10days

2) Fever since 7 days 

HISTORY OF PRESENTING ILLNESS:

                       Patient was apparently asymptomatic 10 days back and later developed -

-severe pain abdomen in the right upper quadrant region of abdomen ,which was sudden in onset,gradually progressive , dragging type and non radiating pain.It is aggravated on standing position and relieved for sometime upon taking medication.Not associated with nausea, vomiting,loose stools.

-And then later developed fever since 1 week which was high grade,continuos type and associated with chills and rigor. It is not associated with Cold,cough, shortness of breath,neck pain,giddiness,headache and sweating.It is relieved mildly upon taking medications

-No complaints of chestpain, palpitations and burning micturition.

HISTORY OF PAST ILLNESS:

                       Patient was admitted in the hospital for 3 days with similar complaints 14 days back and was given IV antibiotics for 3days.

 There is no history of DM/HTN/EPILEPSY/ASTHMA/CVA/CAD.

Treatment history:

 3 day high dose  antibiotics course given 14days back.

PERSONAL HISTORY:

•Appetite ; - decreased since 1 week

•Bowel and bladder;- Regular

                        Micturition-normal

•Addictions;-  toddyconsumption- 1litre/day since 30years

 -Tobacco in the form of beedi- 10/day since 30years

FAMILY HISTORY: 

There is no relavent family history

General physical examination:

The patient is conscious, coherent and cooperative, sitting comfortably on the bed.

- He is well oriented to time, place and person.

- He is moderately built and moderately nourished.

Vitals:

- Temperature = he is now afebrile

- Pulse = 76 beats per minute, regular, normal in volume and character. There is no radio-radial or radio-femoral delay.

- Blood pressure = 110/80 mm of Hg

- Respiratory rate = 16 cycles per minute.

- JVP is normal

-mild icterus is seen on sclera

- There is pedal edema is noticed

Pitting type 

•progressive in nature 

• extent up to ankles

- There is no Pallor, Clubbing, Cyanosis, Generalized lymphadenopathy 

Spo2 -96% on room air 

RR- 16 cpm

CVS -S1S2 heard no murmers 

RS-decreased air entry in right infraaxillary and infrascapular region  and bilateral fine crepitations are present in right lower lobe.

Abdomen examination:

INSPECTION

1)SHAPE of the abdomen: scaphoid

Umbilicus: Normal (inverted)

No visible pulsations 

No Visible peristalsis

All quadrants of abdomen moving equally on respiration.

Palpation :

•No local rise of temperature 

•Tenderness is present over the right hypochondrium.(Right upper quadrant)

•No palpable masses found.

•Liver and Spleen not palpable.

PERCUSSION

Liver span is Normal (11cm)

AUSCULTATION

bowel sounds heard on auscultation

Provisional DIAGNOSIS OF THIS CASE:

Bilateral pedal edema

• Gravitational.
• Venous insufficiency/thrombophlebitis.
• Drugs. NSAIDS. Birth control. Steroids.
• CHF.
• Lymphedema.
• Pretibial myxedema.
• Renal failure.
• Liver failure.

INVESTIGATIONS

CBP

LFT

RFT

CUE

Chest X ray shows mild pleural effusion.

USG abdomen

2d echo

PT ApTT INR

Treatment received till now

PROVISIONAL DIAGNOSIS

Based on right upper quadrant pain,14day fever  pedal edema and mild  icterus and investigations the anatomy of location of the problem confines to Liver.

Based on history of the patient there is underlying liver pathology and bacterial infestation causing liver abcess may be seen and it is confirmed by ultrasound .