Long case - 1601006170
A 55 year old male resident of Miryalaguda , toddy Climber by occupation came to the hospital with the chief complaints of pain abdomen since 14 days and fever for 10 days.
History of present illness:
Patient was apparently asymptomatic 14 days back and then he developed severe pain in right upper quadrant which was sudden in onset, gradually progressive and dragging type and non radiating type .Aggravated on standing position and relieved by medications and pain abdomen was not associated with nausea,vomiting and loose stools.
And then later he developed Fever since 10 days which was high grade and continuous and associated with chills and rigor for 1 day and not associated with Cold, cough, Shortness of breath, headache, giddines and vomiting.
No history of chest pain ,Palpitations ,burning micturition.
Past history :
Patient was admitted in hospital for 3 days with similar complaints 14 days back and was given IV antibiotics for 3 days.
There is no history of Diabetes mellitus,Hypertension,Asthma and epilepsy.
Treatment history: 3 day high dose antibiotics course given 14 days back.
Personal history:
Appetite : decreased since 1 week
Diet: Mixed
Bowel and bladder movements: Regular
No burning micturition
Addictions:
Toddy consumption 1 bottle/day since 30 years
Tobacco in the form of beedi 10/day since 30 years
Family history:
There is no significant family history.
General Examination :
The patient was 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 : Afebrile (at present)
Fever chart:
Pulse : 78 beats per minute, regular,normal in volume and character .There is no radio radial delay and radio femoral delay.
Blood pressure: 110/80 mm of Hg
Respiratory Rate: 16 cycles per minute.
Jvp: normal
No pallor
Icterus: mild yellowish discoloration seen on sclera.
There is
Pedal edema which is pitting type and progressive in nature .
There is no clubbing, Cyanosis and Lymphadenopathy.
Saturation of Oxygen (SpO2)=96% on room air.
Respiratory Rate :16cycles per min
Abdominal Examination :
Shape of abdomen: Slightly Scaphoid
Umblicue:Normal (inverted)
No visible pulsations
No Visible peristalsis
All quadrants of abdomen moving equally on respiration.
Palpation :
No local rise of temperature
Tenderness is present over the right hypochondrium.(Right upper quadrant)
No palpable masses found.
Liver and Spleen not palpable.
Percussion:
Liver span - slightly increased
Auscultation :
Bowel sounds heard.
Respiratory system:
Elliptical & bilaterally symmetrical chest
Both sides moving equally with respiration
Dull note heard on percussion in right infra axillary & infra scapular areas
Bilateral air entry present
Normal vesicular breath sounds
Decreased air entry in right infra axillary & infra scapular areas.
Vocal resonance decreased in right infra axillary & infra scapular areas.
CVS : S1 and S2 heart sounds heard
No murmurs
Complete blood picture:
Liver function tests:
Renal function tests:
Bacterial culture :
Chest X ray :
Ultrasound:
Treatment Received :
Analysis:
Based on upper quadrant pain,14day fever pedal edema and mild icterus and investigations .
Anatomy of location : Liver.
Based on history of the patient there is underlying liver pathology and bacterial infection causing liver abcess may be seen and it is confirmed by ultrasound .
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