1601006032 SHORT CASE

 

Short case - GM 1601006032





A 55 year old male, resident of miryalaguda, toddy climber by occupation, came with chief complaints of
- pain abdomen since 10 days
- fever since 7 days

He was apparently asymptomatic 10 days back. Then he developed pain in the right upper quadrant of abdomen, sudden in onset, dragging type, non radiating, gradually progressive, aggravated on standing, relieved by taking medication.

He developed fever 3 days later, which was high grade, continuous, associated with chills and rigor. It was not associated with burning micturition.

He was admitted in the hospital 14 days back for the same complaints and was given I. V antibiotics.

He consumes toddy 1litre/day and smokes 10 beedi/day since 30 years.

General examination:
- mild icterus
- pitting type of pedal edema upto ankles
- temperature: afebrile (now)

Abdominal examination:
Inspection:
- Shape of the abdomen: normal (slightly scaphoid)
- Umbilicus : normal (inverted)
- All quadrants are moving equally on respiration.

Palpation:
- Tenderness in the right upper quadrant
- No palpable mass

Percussion:
- liver span: normal

Auscultation:
- Bowel sounds: heard

Respiratory system:
- bilateral fine crepitations in the basal regions 


CVS:
- S1, S2 heard; no murmurs


Provisional diagnosis:
- Anatomical location of the problem: liver
- Etiological diagnosis: infection
- USG: liver abscess

Treatment given:
- Inj. Tramadol 
- Inj. Clindamycin
- Inj. Amoxicillin and cloxacillin
- Inj. Pantoprazole
- Inj. Thiamine





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