1601006195 SHORT CASE

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GENERAL MEDICINE  SHORT CASE

HT.No 1601006195

 A 55 year old male from miryalguda labourer by occupation came to opd with chief complaints of 

1.PAIN Abdomen since 15 days

2.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  sudden in onset, gradually progressive,dragging type and non radiating

 aggravated on standing position and relieved by medications and not associated with nausea and vomiting and loose stools  and 

 then later he developed 

 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 value 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 air entry,bilateral fine crepitations are present in right lower lobe and left lower lobe 

ABDOMINAL EXAMINATION

 

INSPECTION 

Shape of the abdomen flat 

Umbilicus : normal 

no visible pulsation

no visible peristalsis

all quadrants of abdomen moving equal with respiration

PALPATION

Inspectory findings are confirmed 

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

AUSCULATION 

bowels sounds are heard 

Provisional diagnosis:LIVER ABSCESS

INVESTIGATIONS 

HEMOGRAM reduced hemoglobin 

Reduced lymphocytes 

 

Liver function test:  

Renal function test: 

Chest x ray:

Ultrasound:

 

TREATMENT:

1.THIAMINE INJECTION 

2.CLINDAMYCIN PHOSPHATE 600mg 

3.TRAMODOL HCL 

4.AMPICILLIN  and CLOXACILLIN 

5.PANTOPRAZOLE INJECTION