1601006085 LONG CASE
HALL TICKET : 1601006085 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 13 days
2) Fever since 10 days
Chief complaints:
A 55 year old male patient, toddy climber by occupation, resident of miryalguda,came with complaints of
1) Pain abdomen since 13 days
2) Fever since 10 days
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 13 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.
- Later he developed fever since 1 week which was high grade,continuos type and associated with chills and rigor but not associated with Cold,cough, shortness of breath,neck pain,giddiness,headache and sweating.It is relieved upon taking medications.
- No H/O of constipation or diarrhoea
- No H/O of vomitings
- No H/O of palpitations
- No H/O of burning micturition
- No H/O of blood in vomitings
- No H/O of pruritus
HISTORY OF PAST ILLNESS:
- Patient was admitted in the hospital for 3 days with similar complaints 17 days back and was given IV antibiotics for 3days.
- Not a K/C/O of DM/HTN/EPILEPSY/ASTHMA/CVA/CAD.
- No H/O of any surgeries in the past .
TREATMENT HISTORY :
High dose antibiotics course given 17 days back for 3 days
PERSONAL HISTORY :
Married for 26years with 2 children a daughter and son.
- Appetite : Decreased appetite since 10 days
- Bowel & bladder movements : Regular
- Micturition : Normal
- Addictions : Toddy consumption- 1litre/day since 30years
FAMILY HISTORY:
No significant family history .
CONSENT OBTAINED
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.
Pedal edema is noticed which is of pitting type ,progressive in nature,extending up to the ankles.
Mild icterus
- No signs of spiderneavi ,palmar erythema,scratch marks
VITALS:
- Temperature = Presently 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 measured in sitting position
- Respiratory rate = 16 cycles per minute
- JVP normal
ABDOMEN EXAMINATION
INSPECTION:
- Shape of the abdomen : scaphoid
- Umbilicus :inverted and slightly retracted
- No signs of any scars or sinuses or distended veins
- All quadrants of the abdomen move with respiration
PALPATION :
- No local rise of temperature
- All inspectory findings are confirmed
- Tenderness in the right upper quadrant of abdomen is noticed
PERCUSSION:
No palpable mass and liver span is 11cm
No free fluid levels
Liver and spleen are not palpable
No bruits are heard
AUSCULTATION :
Bowel sounds heard on auscultation
CVS EXAMINATION -
- S1,S2 heard
- No murmers are heard
RESPIRATORY SYSTEM EXAMINATION:
Decreased air entry in right infraaxillary and infrascapular region and bilateral fine crepitations are in right lower lobe.
Provisional DIAGNOSIS OF THIS CASE:
Bilateral pedal edemaGravitational.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
Treatment received till now :
PROVISIONAL DIAGNOSIS
Based on right upper quadrant pain,17 day 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 .
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