1601006109 LONG CASE
1601006109 long case
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A 55 year old Male Farmer by occupation came with complaints of
1) Severe pain abdomen since 10 days
2) Fever since 7days
Chief complaints:
A 55 year old Male ,Farmer by occupation, resident of Miryalguda ,
came with complaints of :
1) pain abdomen since 10day
2) Fever since 7 days
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 10 days ago then he developed
-severe pain abdomen in the right upper quadrant of abdomen ,
➤which was sudden in onset , gradually progressive , dragging type and non radiating pain.
➤It is aggravated on standing position and relieved for sometime upon taking medication.
➤Not associated with nausea, vomiting, loose stools.
-then he developed high grade fever ,which was continuous for 1 week 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 on 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 ago and was given IV antibiotics for 3days.
There is no history of DM/HTN/EPILEPSY/ASTHMA/CVA/CAD.
Treatment history:
A 3 day high dose antibiotics medication 14days ago
PERSONAL HISTORY:
Appetite -decreased since 1 week
Bowel and bladder-Regular
Micturition-normal
Addictions-
toddyconsumption- 1litre/day since 30years
Tobacco in the form of beedi- 10/day since 30years
FAMILY HISTORY:
There is no relevant family history
General physical examination:
The patient is conscious, coherent and cooperative.
- 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.
- Blood pressure = 110/80 mm of Hg
- Respiratory rate = 16 cycles per minute.
- JVP is normal
- icterus is seen on sclera
- There is pedal edema which is Pitting type
•progressive in nature
• extent up to ankles
There is no signs of Pallor, Clubbing, Cyanosis, Generalized lymphadenopathy
Spo2 -96% on room air
RR- 16 cpm
CVS -S1S2 heard no murmers
RS-decreased air entry in right infraaxillary and infrascapular region and bilateral fine crepitations are present in right lower lobe.
Abdomen examination:
INSPECTION
1)SHAPE of the abdomen: symmetrical
PALPATION
2) tenderness in the right upper quadrant of abdomen noticed
percussion
3)There is no palpable mass and liver span is 11cm.
4) hernial orifices are normal and umbilicus normal
5) There's no free fluid level
6)No bruits heard
7)Liver not palpable
8)spleen not palpable
AUSCULTATION
9)bowel sounds heard on auscultation.
INVESTIGATIONS
CBP : low hbg, normocytic normochromic anemia
low lymphocyte count
LFT: 
elevated serum total bilirubin, direct bilirubin, low albumin levels.
CULTURE reports:
Methicillin sensitive staphylococcus aureus
Plain radiograph of thorax showing right lower pleural effusion
USG : 
Hetro echoic collections in right lobe of liver are seen.
APTT : normal
PROVISIONAL DIAGNOSIS OF THIS CASE :
based on the investigations: liver abscess.
Treatment recieved :
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