1601006183 LONG CASE

 

Long case 1601006183

GENERAL MEDICINE FINAL PRACTICAL CASE:

Long case :

"This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

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 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 in abdomen and fever.

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 1 week.

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.

-No complaints of chestpain, 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

Sleep - Decreased due to pain

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 relavent 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 chart -

- Pulse: 76 beats per minute, regular, 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

     - Extent up to ankles

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

Spo2 -96% on room air

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:

1) Shape of the abdomen: Normal

2) Tenderness in the right upper quadrant of abdomen noticed

3) There is no palpable mass

4) Hernial orifices are normal

5) There is no free fluid 

6) Liver not palpable

7) Spleen not palpable

8) Bowel sounds heard

AUSCULTATION :

Bowel sounds heard

PERCUSSION :

Liver span is normal (11Cm)

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

PROVISIONAL DIAGNOSIS : Liver Abscess

INVESTIGATIONS:

Complete blood picture

Liver function test

X ray - chest

Ecg

Ultrasound

Treatment given

- metronidazole

-thiamine

-clindamycin

-tramadol

-ampicillin

-pantoprazole

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

Diagnosis - Pyogenic liver abscess because all findings point towards liver abscess and culture report points towards Staph Aureus which is pyogenic