1601006163 LONG CASE

 

LONG CASE (1601006163)

GENERAL MEDICINE FINAL PRACTICAL CASE:

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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. 

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 THE PATIENT'S PROBLEM :

The problems in order of priority I found are:

1. Severe pain abdomen since 10 days
2. Fever since 7 days.
3. Decreased appetite since 7 days.

✦ CHIEF COMPLAINTS:

    A 55 year old male patient, toddy climber by occupation, resident of Miryalguda, came with complaints of : 

1. Pain abdomen since 10 days
2. Fever since 7 days.
3. Decreased appetite since 7 days.

✦ HISTORY OF PRESENTING ILLNESS: 

    Patient was apparently asymptomatic 10 days back and later developed :

1. Severe pain abdomen in the right upper quadrant region of abdomen, which was sudden in onset, gradually progressive, dragging type and non radiating. It is aggravated on standing position and relieved for sometime upon taking medication.
2. He later 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, neck pain, giddiness, headache and sweating. It is relieved mildly upon taking medications.
3. 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 3 days.

• There is no history of DM /HTN /EPILEPSY/ ASTHMA /CVA /CAD.

✦ TREATMENT HISTORY:

• 3 day high dose antibiotics course given 14 days back.

✦ PERSONAL HISTORY:

• Appetite - Decreased since 1 week
• Bowel and bladder - Regular           
• Micturition - Normal
           -Addictions : Toddy consumption -1 bottle/day since 30 years.
                                →Tobacco in the form of beedi - 10/day.

✦ FAMILY HISTORY: 

  • There is no relevant 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. The condition of the arterial wall is normal.

•  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

 → Pitting type

 → Progressive in nature
 → Extent up to ankles

→ There is no Pallor, Clubbing, Cyanosis, Generalized lymphadenopathy 

→ Spo2 -96% on room air.

 

→ RR- 16 cpm

→ Cardiovascular System - S1, S2 heard, no murmurs 

→ Respiratory System - Decreased air entry and bilateral fine crepitations are present in right lower lobe and left lower lobe.

✦ Abdomen examination:

  ➤ INSPECTION

• Shape of the abdomen: scaphoid

• PALPATION

         Tenderness in the right upper quadrant of abdomen noticed.

    ✦ PERCUSSION

• There is no palpable mass
• Hernial orifices are normal
• There is no free fluid 
• Liver not palpable
• Spleen not palpable

    ✦ AUSCULTATION

• Bowel sounds heard

✦ Provisional DIAGNOSIS OF THIS CASE:

     Bilateral pedal edema

• Venous insufficiency/thrombophlebitis.
• Drugs. NSAIDS. Steroids.
• CHF.
• Lymphedema.
• Pretibial myxedema.
• Renal failure.
• Liver failure.

PROVISIONAL DIAGNOSIS : Liver Abscess

INVESTIGATIONS:

Complete Blood Picture

Liver Function Tests

Renal Function Tests

Culture & Sensitivity Report:

Chest X ray

USG abdomen

  

 Impression: heteroechoic collection noted in the rt. Lobe of liver suggestive of liver abscess.

PT ApTT INR

✦ TREATMENT RECIEVED TILL NOW: 

• metronidazole
• thiamine
• clindamycin
• tramadol
• ampicillin
• pantoprazole

    ➤  DRUGS GIVEN:

• PERCUTANEOUS DRAINAGE WITH PIGTAIL'S CATHETER WAS DONE TO DRAIN THE ABSCESS

✦ PROVISIONAL DIAGNOSIS:

 → Based on upper quadrant pain, 14day 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 abscess may be seen and it is confirmed by ultrasound.