short case
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A 50 year old male patient farmer by occupation came to the opd with the chief complaints of abdominal pain since 1 month
Chest xray
HISTORY OF PRESENT ILLNESS :
Patient was apparently asympomatic 1 month back, then he developed abdominal pain after consumption of food in epigastric region and right iliac region
Pain:
Squeezing type of pain , increases after food consumption and after lifting heavy weights andnon radiating type relieves on its own.
Pain lasts for 30 minutes during the episode.
No history of fever ,weightloss,vomitings, diarrhoea and constipation
HISTORY OF PAST ILLNESS :
N/k/c/o DM, HTN, Asthma , epilepsy, TB .
No history of similar complaints in the past.
DRUG HISTORY :
No allergies to known drugs
NO history of previous medication
PERSONAL HISTORY :
Diet - Mixed
Appetite - normal
Micturition-normal
Bowel and bladder movements- Regular
Sleep- disturbed
Addictions -
Patient consumes alcohol since 30 years
smokes cigarette (8-10) or full pack since 30 years
chews pan (3-4 times )daily.
FAMILY HISTORY :
No significant family history
GENERAL EXAMINATION :
Patient was examined after taking his consent.
Patient was conscious, coherent, cooperative and well oriented to time place and person
Patient was well nourished and well built.
Pallor- Absent
Icterus- absent
Clubbing- absent
Cyanosis- absent
Lymphadenopathy - absent
Edema- absent.
VITALS:-
Temperature: afebrile
Blood pressure:130/80mmhg
Pulse rate:88 bpm.
Respiratory rate:16 cpm
SYSTEMIC EXAMINATION :
ABDOMEN-:
Inspection:
Shape of the abdomen- Scaphoid
Flanks: flanks are free
Umbilicus- central and inverted.
no visible sinuses and scars are seen.
No engorged veins
No visible pulsations
Palpation:
No local rise of temperature
No tenderness
No palpable mass
No organomegaly.
Percussion:
No Fluid thrill
No shifting dullness
Tympanic note on percussion of abdomen
Auscultation:
Bowel sounds are heard.
RESPIRATORY SYSTEM :
Chest is bilaterally symmetrical
Trachea is central
Movements with respiration are equal on both sides
Bilateral air entry present
Resonant sounds on percussion
Vesicular breath sounds are heard on Auscultation
CVS :-
Elliptical and bilaterally symmetrical chest
No engorged veins
No scars/sinuses
Novisible pulsations
S1&S2 heard
No murmurs
No thrills
CNS-:
Consious, coherent ,cooperative
Speech normal
No neck stiffness
No meningeal signs
Motor system normal
Sensory system normal
Able to percieve-:pain , temp.
Cranial nerves : intact
PROVISIONAL DIAGNOSIS :
Gastritis
Cholelithiasis
Cholecystitis
Liver disease
INVESTIGATIONS:
Complete blood picture
USG abdomen
CT scan
Liver function tests
FINAL DIAGNOSIS:
Liver abscess
TREATMENT:
T pan 40 mg po/od.
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