1601006144 LONG CASE

 Long case

HALL TICKET NO. 1601006144

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CASE:

A 55 year old male, a toddy climber from Miryalaguda came to the OPD with complaints of pain abdomen since 10 days and, fever since 7 days

 

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 10 days back and then developed

•Severe, dragging type of pain abdominal pain in the right upper quadrant, sudden in onset, which was gradually progressive, and non radiating

•Aggravated on standing and relieved on taking medication for a little while. 

•The pain is not associated with nausea, vomiting or loose stools.

•Developed a fever 3 days later which was high grade and continuous type, associated with chills and rigors. 

•Not associated with cough, shortness of breath, giddiness, headache or sweating.

•It is relieved upon taking medication.

•No complaints of chest pain or palpitations.

HISTORY OF PAST ILLNESS:

14 days ago, the patient had similar complaints and was admitted to a local hospital (3 days) and was treated with IV antibiotics.

No history of Diabetes Mellitus, Hypertension, Asthma, Epilepsy or Coronary artery disease.

TREATMENT HISTORY:

 Antibiotic therapy given 14 days ago (hospital stay)

PERSONAL HISTORY:

• Diet- mixed

•Appetite -decreased since 1 week

• Bowel and bladder-Regular

• Addictions- 

Toddy consumer since 30 years, 1litre/day

FAMILY HISTORY: 

There is no relavent family history

GENERAL PHYSICAL EXAMINATION:

•The patient is conscious, coherent and cooperative, seated comfortably on a bed, well oriented to time, place and person.

•He is moderately built and moderately nourished.

Vitals

•Pulse = 76 beats per minute, regular, 

normal in volume and character. 

no radio-radial or radio-femoral delay.

•Blood pressure = 110/80 mm of Hg

•Respiratory rate = 16 cycles per minute.

•JVP is normal

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

• Mild icterus seen

• Pitting type of pedal edema is noticed (up to ankles)

CARDIOVASCULAR SYSTEM:

 •S1, S2 heard. No murmurs 

RESPIRATORY SYSTEM:

Decreased air entry in right infra-axillary and infrascapular region and fine crepitations noticed in right lower lobe.

ABDOMINAL EXAMINATION:

• inspection:

Shape of abdomen is scaphoid

Umbilicus central and inverted 

• palpation:

tenderness in the right upper quadrant

No palpable mass

Liver and spleen not palpable

• percussion:

No free fluid levels

• auscultation:

Bowel sounds heard

INVESTIGATIONS:

Complete Blood Picture

Liver Function Test

Blood Clotting Studies

Renal Function Test

Culture and Sensitivity

Ultrasonography

X-ray Chest

Showing pleural effusion of both lungs

PROVISIONAL DIAGNOSIS:

Based on history, upper right quadrant pain, pedal edema and liver function tests confine the problem to the Liver, more specifically a Liver Abscess that is confirmed by ultrasound.