1601006160 SHORT CASE

 

Short case



Hall ticket no.:1601006160


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 A 55year old male toddy climber by occupation, hailing  from miryalaguda came to the opd with 

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 chestpain, 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- 
toddyconsumption- 1litre/day since 30years
Tobacco in the form of beedi- 10/day since 30years

GENERAL EXAMINATION:

 consent has been taken before examining the patient
Patient is concious,coherent and cooperative sitting comfortably on bed .

He is well oriented to time, place and person and 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 Up to ankle.

ABDOMINAL EXAMINATION

On inspection
Shape of abdomen : Normal 
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 11 cm.
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:
 Percussion  right infra axillary & infra scapular stony  dull note 
Auscultation  decreased air entry in right infra axillary & infrascapular

INVESTIGATION:

CBP :
Decrease in lymphocyte count.

chest x ray 
Right pleural effusion.

PROVISIONAL DIAGNOSIS:

Based on history , examination followed by investigations my probable diagnosis is liver abscess

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