1601006061 LONG CASE

 Hall ticket no. 1601006061

    

"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.                                                          

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 patient, resident of miryalaguda, who is a toddy climber by occupation came to the medicine out patient department with Chief complaints of pain abdomen and fever.

chief complaints 

1) Severe pain abdomen since 10 days.

2) Fever since 7 days.

history of present illness

                       Patient was apparently asymptomatic 10 days ago and then developed - pain abdomen in the right hypochondrium ,which was sudden in onset, gradually progressive , dragging type and non radiating pain. It is aggravated on standing and relieved for sometime upon taking medication.

Not associated with nausea, vomiting, loose stools.

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

-No complaints of chest pain, 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:

               Sleep: adequate

               Diet: mixed 

               Appetite -decreased since 1 week

               Bowel and bladder -Regular 

               micturition -normal

               Addictions - toddy consumption-  1litre/day since 35years.

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

Patient practices open defecation at a well near his working place.

FAMILY HISTORY: 

There is no relevant family history

General physical examination:-

-Consent has been taken from the patient for 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

- pedal edema is noticed of pitting type 

                                               •progressive in nature 

                                               • extent up to ankles

Pallor present

- There is no Clubbing, Cyanosis, and Generalized lymphadenopathy 

-Spo2 -96% on room air 

-RR- 16 cpm

-CVS -S1b& S2 heard; no murmurs 

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

Abdomen examination:

INSPECTION

- SHAPE of the abdomen: scaphoid

- no visible scars and sinuses

- no engorged veins

- no visible pulsations 

- umbilicus is central 

PALPATION
- no local rise in temperature

- tenderness in the right hypochondriac region of abdomen noticed.

- no organomegaly 

PERCUSSION

- There's no free fluid level

AUSCULTATION

- bowel sounds heard on auscultation

- no bruit heard 

INVESTIGATIONS

CBP

LFT

RFT

culture and sensitivity

chest x-ray 

right sided pleural effusion can be seen 

USG ABDOMEN 

PT and INR

aPTT

 

Treatment received

- metronidazole

-thiamine

-clindamycin

-tramadol

-ampicillin

-pantoprazole

PROVISIONAL DIAGNOSIS

Based on right hypochondrium  pain, fever  pedal edema and mild icterus and investigations the anatomical location of the problem confines to Liver.

Based on history of the patient and ultrasound findings my provisional diagnosis is liver abscess.