A 50 year old male patient with abdominal pain SHORT CASE
January 20 , 2023
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Date of admission: 16-01-2023
Cheif complaint :
A 50 year old male, farmer by occupation came to the opd with the chief complaints of abdominal pain since 1 month .
History of present illness :
Patient was apparently asymptomatic 1 month back then he developed abdominal pain in epigastric region after consumption of food . Pain is present which is squeezing type of pain, non radiating, increases after food consumption and relieving on its own.
Pain lasts for 30 minutes during the episode
No h/o weight loss , vomitings ,diarrhoea or constipation no loss of appetite , fever ,
blood in stools , burning micturition ,
shortness of breath , regurgitation of food.
Past history :
Patient met with an accident 16 years back , fracture of teeth.
No similar complaints in the past.
H/O Hypertension since 1 year (telmisartan 40 mg OD, amlodipine 4 mg)
H/O scabies 1 year ago ( resolved now)
Not a know case of DM, Asthma, Epilepsy, CAD, TB.
No h/o drug allergy
Personal history:
Diet - Mixed
Appetite - normal
Bowel and bladder movements- Regular
Sleep- adequate.
Addictions -
Alcohol : Patient consumes alcohol occasionally ( twice weekly 150 ml)
Smoking :cigarette (8-10 or a box full per day)
Chews khaini and betel leaf(pan) 3-4 times daily.
Family history:
-No significant family history.
General examination:
By taking consent of patient I have examined him in a well lit room
Patient was conscious, coherent, cooperative, well oriented to time place and person .
Well nourished and well built
No pallor icterus cyanosis clubbing lymphadenopathy edema
Vitals:
Temperature: afibrile
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- centrally placed and inverted.
Sinuses and scars dilated veins are not seen.
No visible pulsations
All quadrants are moving equally on respiration
Bruits: No
Palpation:
Temperature : no local rise in temperature
Tenderness - in right hypochondriac region.
No palpable mass
No organomegaly.
Liver and spleen are not palpable
Percussion:
Resonant node heard
Thrill - not heard
Shifting dullness absent
Auscultation:
- Bowel sounds are heard
Respiratory examination:
Inspection
Chest - bilaterally symmetrical.
Movements are equal on both sides during respiration
Palpation
Trachea - Central
Bilateral air entry is present
Normal Vesicular breath sounds are heard.
Cardiovascular examination:
Chest - bilaterally symmetrical
Shape - elliptical
Sinuses scars dilated veins are not seen
S1 , S2 heard
No murmurs.
No trills
CNS examination:
Patient is concious coherent cooperative
Speech is normal.
Intelligence - good
Motor and sensory system:normal
No hallucinations
No meningeal signs
Provisional Diagnosis :-
Liver abscess , HTN
Clinical pictures :
Investigations -
USG
DIAGNOSIS:
Liver abscess
TREATMENT:
T pan 40 mg po/od.
Ampicillin2g, gentamicin , metronidazole-500 mg
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