1601006011 long case

Hall ticket no.1601006011

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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 comprehending 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 abdomen and fever.

Following is my analysis of this patient's problem:

The problems in order of priority I found are 

1) Severe pain abdomen since 14 days

2) Fever since 7days

Chief complaints: 

                            A 55 year old male patient,toddy climber by occupation, resident of miryalguda,came with complaints of 

1)pain abdomen since 10days

2) Fever since 7 days 

HISTORY OF PRESENTING ILLNESS:

         Patient was apparently asymptomatic 10 days back and later developed -

 

     -severe pain abdomen in the right upper 

    ~  Region--right upper quadrantof abdomen ,.         ~Onset.  -sudden 

      ~Gradually progressive

      ~Type -dragging type 

      ~non radiating pain.

      ~Aggravating on standing position 

      ~Relieved for  sometime upon taking medication.

 And pain abdomen not associated with nausea , vomiting ,loose stools 

   -And then later developed fever since 1 week 

   

   FEVER-high grade

     continuos type and associated with chills and rigor. 

      It is not associated with Cold,cough, shortness of breath,neckpain,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 3days.

 There is no history of DM/HTN/EPILEPSY/ASTHMA

Treatment history: 3day high-dose  antibiotics course given 14days back.

PERSONAL HISTORY:

                       Appetite -decreased since 1 week

                        Bowel and bladder-Regular

                        Micturition-normal

              Addictions- 

toddyconsumption- 1bottle/day since 30years

Tobacco in the form of beedi- 10/day since 30 years

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 = 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

-mild icterus is seen on sclera

There is pedal edema is noticed

Pitting type 

•progressive in nature 

• extent up to ankles

There is no Pallor, Clubbing, Cyanosis, Generalized lymphadenopathy 

Spo2 -96% on room air 

RR- 16 cpm

CVS -S1S2 heard no murmers 

RS-  Percussion - right infra axillary & infra scapular dull note

       Auscultation -decreased air entry in right infra axillary & infrascapular

Abdominal examination::

Umbilicus: Normal (inverted)

No visible pulsations 

No Visible peristalsis

All quadrants of abdomen moving equally on respiration.

1)SHAPE of the abdomen: scaphoid

2) There is  abdominal tenderness on Right upper quadrant                

                                               

3)Liver span normal 11 cm

Auscultation

 Bowel sounds heard

Liver and spleen not palpable

DIAGNOSIS OF THIS CASE:

INVESTIGATIONS

COMPLETE BLOOD PICTURE

LFT

RFT

X RAY

ECG report

Culture and sensitivity report

       

USG abdomen

Treatment::

Analysis::

MY THOUGHTS IN THIS CASE

Based on right upper quadrant pain,14day fever  pedal edema and mild  icterus and investigations THE anatomy of location of the problem confines to Liver.

Based on history of the patient there is underlying liver pathology and bacterial infestation causing liver abcess may be seen and it is confirmed by 

Ultrasound