1601006044 LONG CASE

 

1601006044 : LONG CASE




     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.


   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: 55year old male resident of miryalaguda, toddy climber by occupation came with chief complaints of 

• Severe pain abdomen since 10 days

•Fever since 7days.

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 
-Insidious in onset
-Gradually progressive
-Dragging type 
-Non radiating pain
-It is aggravated on standing position
-Relieved for sometime upon taking medication
-Not associated with nausea, vomiting, loose stools.

•Fever :
-Since 1 week
-High grade
-Continuos type 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 : 
-DIABETES MELLITUS 
-HYPERTENSION
-EPILEPSY
-ASTHMA
-CEREBROVASCULAR ACCIDENTS 
-CORONARY ARTERY DISEASE. 

Treatment history:
Antibiotics of 3 day course is given 14 days back for similar complaints in the past.

PERSONAL HISTORY:
                       
Appetite -decreased since 1 week                    
Bowel and bladder-Regular                        
Micturition-normal              
Addictions- 
Toddy consumption- 1litre/day since 30 years
Tobacco in the form of beedi- 10/day since 30 years

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 bilateral pedal edema is noticed: 

 •Pitting type 
 •Progressive in nature 
 •Extent up to ankles




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

-Spo2 -96% at room air.
-RR- 16 cpm.

CVS -S1&S2 ; heard no murmurs

RS- Elliptical & bilaterally symmetrical chest
Both sides moving equally with respiration

Dull note heard on percussion in right infra axillary & infra scapular areas

Bilateral air entry present
Normal vesicular breath sounds
Decreased air entry in right infra axillary & infra scapular areas.
Vocal resonance decreased in right infra axillary & infra scapular areas.


Abdomen examination:

INSPECTION
•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
•There is no palpable mass and liver span is 11cm




AUSCULTATION
•Bowel sounds heard on auscultation.




INVESTIGATIONS
CBP
LFT

RFT



Chest X ray shows mild pleural effusion.

USG abdomen
 
BACTERIAL CULTURE 




Treatment received till now

PROVISIONAL DIAGNOSIS:

Pyogenic liver Abcess.


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