1601006051 LONG CASE

HALL TICKET NO. 1601006051

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 patient, resident of miriyalaguda, who is a toddy climber by occupation came to the medicine out patient department with Chief complaints of pain abdomen and fever.


The chief complaints in order of chronology I found are 

1) Severe pain abdomen since 10 days.

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 quadrant region of abdomen ,which was sudden in onset, gradually progressive , dragging type and non radiating pain. It is aggravated on standing and relieved for sometime upon taking medication.
Not associated with nausea, vomiting,loose stools.

-And then later he 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 ,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/CVA/CAD.

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

PERSONAL HISTORY:
               Sleep: adequate
               Diet: mixed
               Appetite -decreased since 1 week
               Bowel and bladder -Regular 
               micturition -normal
               Addictions - toddyconsumption-                                                           1litre/day since 35years.
-Tobacco in the form of beedi- 10/day since 30years
Patient practices open defecation at a well near his working place.

FAMILY HISTORY: 
There is no relavent family history

General physical examination:-

-Consent has been taken from the patient for 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

- pedal edema is noticed of pitting type 
                                               •progressive in nature 
                                               • extent up to ankles


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

-Spo2 -96% on room air 
-RR- 16 cpm

-CVS -S1b& S2 heard; no murmurs 

- 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: scaphoid
PALPATION
2) tenderness in the right hypochondriac region 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
LFT

RFT

Bacterial culture and sensitivity report:

Chest X ray shows mild pleural effusion.

USG abdomen:
Impression: heteroechoic collection noted in the rt. Lobe of liver suggestive of liver abscess.

2d echo
PT ApTT INR


Treatment received till now
- metronidazole
-thiamine
-clindamycin
-tramadol
-ampicillin
-pantoprazole

PROVISIONAL DIAGNOSIS


Based on right upper quadrant pain,14day fever  pedal edema and mild  icterus and investigations the anatomical location of the problem confines to Liver.
Based on history of the patient and ultrasound findings my provisional diagnosis is liver abscess.