1601006197 short case
1601006197 SHORT CASE
Hall ticket number 1601006197
Case: A 55year old male toddy climber by occupation came with complaints of pain abdomen and fever.
Following is my analysis of this patient's problem:
The problems in order of priority I found are
1) Severe pain abdomen since 14 days
2) Fever since 7days
Chief complaints:
A 55 year old male patient,toddy climber by occupation, resident of miryalguda,came with complaints of
1)pain abdomen since 14days
2) Fever since 7 days
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 14 days back and later developed -
-severe pain abdomen in the right upper
~ Region--right upper quadrantof abdomen ,. ~Onset. -sudden
~Gradually progressive
~Type -dragging type
~non radiating pain.
~Aggravating on standing position
~Relieved for sometime upon taking medication.
And pain abdomen not associated with nausea , vomiting ,loose stools
-And then later developed fever since 1 week
FEVER-high grade
continuos type and associated with chills and rigor.
It is not associated with Cold,cough, shortness of breath,neckpain,giddiness,headache and sweating.It is relieved mildly upon taking medications
-No complaints of chestpain, palpitations and burning micturition.
Abdominal examination::
Umbilicus: Normal (inverted)
No visible pulsations
No Visible peristalsis
All quadrants of abdomen moving equally on respiration.
1)SHAPE of the abdomen: scaphoid
2) There is abdominal tenderness on Right upper quadrant
3)Liver span normal 11 cm
Auscultation
Bowel sounds heard
Liver and spleen not palpable
MY THOUGHTS IN THIS CASE
Based on right upper quadrant pain,14day fever and investigations THE anatomy of location of the problem confines to Liver.
Based on history of the patient there is underlying liver pathology and bacterial infestation causing liver abcess may be seen and it is confirmed by
Ultrasound
