1601006041 SHORT CASE

  35 year old male patient with pain abdomen and fever

GENERAL MEDICINE E LOG BOOK

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome."

SHORT CASE

A 55year old male toddy climber by occupation from miryalaguda came to the opd with complaints of pain abdomen and fever 

CHIEF COMPLAINTS

1)pain abdomen since 10days

2) Fever since 7 days 

3)pedal edema 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, continuous type and associated with chills and rigor. Relived mildly on taking medications.

 It is not associated with Cold,cough, shortness of breath,neck pain,giddiness,headache and sweating. 

No complaints of chest pain, palpitations and burning micturition.

He subsequently developed pedal edema in legs since 1week which is progressive in nature and seen at ankles .

PERSONAL HISTORY:

Appetite -decreased since 1 week

  Bowel and bladder-Regular

  Micturition-normal

  Addictions-  toddy consumption- 1litre/day since 30years

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

GENERAL EXAMINATION:

Patient is concious,coherent and cooperative sitting comfortably on bed .

He is well oriented to time, place and person 

He is moderately built and moderately nourished.

VITALS :

Temperature : afebrile

Pulse: 76 beats per min 

Regular ,No radio radial delay .

Blood pressure: 110/80 mm hg

Respiratory rate : 16 cycles /min

JVP is normal 

Pallor : absent 

Icterus : Mild icterus on sclera 

clubbing : absent 

Koilonychia : absent 

Lymphadenopathy: absent 

Edema : pedal edema which is progressive in nature noted in lower limbs .

ABDOMINAL EXAMINATION

On inspection

Shape of abdomen : flat  

Umbilicus is inverted and central.

Movements : All the quadrants are moving equally with respiration.

Scar is present on RUQ : pig tail catheter is placed.

PALPATION:

Tenderness is noted in right upper quadrant .

There is no palpable mass in the abdomen .

Liver is not palpable .

Spleen is not palpable .

PERCUSSION:

Liver span is normal that is 11cm

No free fluid in the abdomen .

AUSCULTATION:

Bowel sounds are heard on auscultation 1 gurgling for every 7 secs 

CVS EXAMINATION:

S1, S2 heard.

RESPIRATORY EXAMINATION:

Decreased air entry and bilateral fine crepitations are heard at Right middle and lower lobes and Left Lower lobe .

On percussion stony dull note on Right and left lower quadrants.

INVESTIGATION:

chest x ray 

Bilateral pleural effusion.

PROVISIONAL DIAGNOSIS:

Based on right upper quadrant pain and bilateral pedal edema,mild icterus my diagnosis is related to liver ,which is confirmed by ultrasound and bacterial culture reports so my probable diagnosis is LIVER ABSCESS