1601006094 LONG CASE
1601006094( LONG CASE)
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CASE:
A 55 Year Old Male Resident of Miryalaguda, toddy climber by occupation came to the hospital with
Chief complaints:
Pain abdomen since 14 days
Fever since 10 days
History of present illness:
The patient was apparently asymptomatic 14 days back. Then he developed severe pain in the Right Upper Quadrant which was sudden in onset, gradually progressive, dragging type and non-radiating in nature. Relieved by medications. Not associated with nausea, vomiting, loose stools.
Later he developed fever since 10 days which was high grade, continuous and not associated with cold, cough, chest pain, shortness of breath, burning micturition.
Past History:
Patient was admitted in the Hospital for 3 days with similar complaints and was given IV antibiotics for 3 days.
There is no history of Diabetes Mellitus, Hypertension, Asthma, Epilepsy.
Treatment History:
3 day high dose antibiotics course given 14 days back.
Personal History:
Sleep : adequate
Diet : mixed
Appetite : decreased since 1 week
Bowel& Bladder : regular
Addictions : toddy consumption 1L/day since 35 years
tobacco in the form of beedi 10 per day since 30 years
Family History:
There is no relevant family history.
General Physical Examination:
Consent has been taken from the patient for examination.
The patient is conscious, coherent, cooperative, sitting comfortable on the bed.
He is well oriented to time, place, person.
He is moderately built and moderately nourished.
Vitals:
Temperature: He is now afebrile.
Fever Chart:
Pulse: 76 beats per minute, regular, normal in volume and character. There is no radio radial or radio femoral delay.
Blood Pressure:110/80 mm of Hg.
Respiratory rate: 16 cycles per min.
JVP: Normal
No pallor
Mild icterus is seen on sclera
pedal edema is noticed- pitting type, extent upto knees.
There is no clubbing, cyanosis, generalised lymphadenopathy
spo2: 96% on room air
Respiratory rate: 16 cpm
Abdominal Examination:
Inspection:
Shape of Abdomen: Flat(slightly scaphoid)
Umbilicus: normal
No visible peristalsis
All quadrants are moving equally on respiration
palpation:
No local rise of temperature
Tenderness in the right hypochondriac region.
Hepatomegaly present
spleen not palpable.
Percussion:
Liver span is 15 cm
Auscultation:
Bowel sounds heard
RESPIRATORY SYSTEM:
Elliptical and bilaterally symmetrical chest.
Both sides moving equally with respiration.
Dull note heard on percussion in right infraaxillary and infrascapular areas.
bilateral air entry present.
Normal vesicular breath sounds heard.
Decreased breath soumds in right infraaxillary and infrascapular areas.
Vocal resonance decreased in right infraaxillary and infrascapular areas.
CVS:
S1 and S2 heart sounds heard.
no murmurs
INVESTIGATIONS:
CBP
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