hall ticket no : 1601006120 General medicine final practical short case : A 55 year old male with Pain Abdomen

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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 55 year old male from miryalguda  he is labourer by occupation came to opd with chief complaints of pain Abdomen since 15 days and 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 a sudden onset, gradually progressive and dragging type and non radiating

 aggravated on standing position and relieved by medications and pain Abdomen was not associated with nausea and vomitingand lose stools  and 

pain abdomen was not associated with nausea and vomiting and loose stools and then later he developed a 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 

Ictress 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 their entry bilateral fine crepitations are present in right lower lobe and left lower lobe 

 abdominal examination 

Shape of the abdomen flat 

Umbilicus : normal 

no visible pulsation

 no visible peristalsis

 all quadrants of abdomen moving equal with respiration

 palpation :: all inspector findings are confirmed by palpation 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

 auscultation:: bowels sounds are heard 

Investigations HEMOGRAM reduced hemoglobin 

Reduced lymphocytes 

Liver function test ::   

Renal function test  

Chest x ray 

Ultrasound 

 

Treatment. Received

* THIAMINE INJECTION 

* CLINDAMYCIN PHOSPHATE 600mg 

*TRAMODOL HCL 

*AMPICILLIN  and CLOXACILLIN 

*PANTOPRAZOLE INJECTION