1601006105 SHORT CASE

1601006105 short case


A 55 year old male from miryalguda  he is labourer by occupation came to opd with chief complaints of 
pain Abdomen since 15 days
fever for 12 days 


 History of presenting illness ::  
           patient was apparently asymptomatic 15 days back and then he developed 
                       severe pain in the right upper quadrant which was a sudden onset, gradually progressive and dragging type and non radiating
 aggravated on standing position and relieved by medications and pain Abdomen was not associated with nausea and vomiting and loose stools and
 then later he developed a fever since 12 days which was high-grade and continuous and associated with chills and rigors for one day and
 not associated with the cold and cough ,shortness of breath, headache ,dizziness and vomiting
 no history of chest pain, palpitation ,burning micturition  .

Past history :  no similar complaints in the past. not a known case of diabetes mellitus, hypertension, asthma and epilepsy and tuberculosis.

Personal history  :: appetite decreased since one week 
diet mixed 
bowel and bladder - regular
 no burning micturition 
he is a toddy drinker since 30 years 
He smokes 10 beedis per day since 30 years 


Family history: 
there is no significant family 

General examination :
Patient was conscious ,coherent and cooperative sitting comfortable on the bed.
 
He is well oriented to time place and person

 moderately built and moderately Nourished 

Icterus is present 

there is a pitting type pedal edema 

No signs of pallor ,clubbing ,cyanosis and generalized lymphadenopathy.

 VITALS   

Pulse:  78 beats /min regular ,normal volume and character, there is no radio radial and radio femoral delay 
Blood pressure :110 /80 mmHg ,left arm in supine position .
Respiratory rate :16 cycles per minute

JVP normal

Temperature : Afebrile

Fever chart:


 
Systemic examination :
CVS S1 S2 heard, no murmurs 

Respiratory system examination:
 decreased bilateral air entry, 
fine crepitations are present in right lower lobe and left lower lobe 

 Abdominal examination :

Shape of the abdomen flat 


Umbilicus : normal 
no visible pulsation
no visible peristalsis
all quadrants of abdomen moving equal with respiration

palpation ::
all inspector findings are confirmed by palpation. no local rise of temperature,
tenderness is present over the right hypochondrium.
right upper quadrant .
no palpable mass 

Liver and spleen or not palpable.

percussion :liver span is normal

Auscultation:: bowels sounds are heard 

Investigations 

HEMOGRAM: reduced hemoglobin 
Reduced lymphocytes 

Liver function test ::   


Renal function test  


Chest x ray 

Ultrasound 

 

Treatment. Received

*THIAMINE INJECTION 
*CLINDAMYCIN PHOSPHATE 600mg 
*TRAMODOL HCL 
*AMPICILLIN  and CLOXACILLIN 
*PANTOPRAZOLE INJECTION

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