55yr old female with fever, abdomen pain.
ROHITH SOMANI
MBBS 9th semester
roll no:127
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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 diagnosis and treatment plan.
Chief complaints::
55 yrs old female came to opd with chief complaints of FEVER since 7 days and abdominal pain since 4 days shortness of breath since 4days.
History of present illness:
Patient was apparently asymptomatic 7 days back then developed fever which was insidious in onset intermittent not associated with chills and rigor relieved on medications
Not associated with vomitings,loose stools
Abdominal pain which more in right upper quadrant is insidious in onset, gradually progressive initially pain is in right upper quadrant now radiating towards right and back stabbing type of pain no relieving and aggrevating factors
Shortness of breath is insidious in onset gradually progressive grade 1-2
Routine history:
Patient was a daily wage worker by occupation her daily routine was not disturbed on daily before onset of fever then abdominal pain which was severe during yesterday so admitted at hospital
Past history::
No similar complaints in past
No history ofDM,HTN,epilepsy,TB
Personal.history::
Appetite ::loss of appetite
Diet.mixed
Bowel and bladder..regular
Addictions..occasionally toddy
No history of allergy to food or drug
Family history::
Insignificant
General examination::::
Patient was examined in a well light room with prior consent
Built:moderate
Nousihment:moderate
No pallor,mild icterus,no cyanosis,no clubbing ,no koilonychia ,no LYMPHADENOPATHY
Bp .120/80mm of Hg
RR..23c/min
Pulse rate..120beats/min
Temperature:99 f
Systemic examination:::
Abdominal::
Inspection..
Shape of abdomen...scaphoid
Umbilicus..inverted,central located
No sinuses or scars on abdomen
Palpation::
No rise in temperature
Tenderness present over right upper quadrant hypochondrium and epigastrium
No palpable mass
No free fluid
Liver palpable and tender
Spleen not palpable
Percussion::
Dull note on right upper quadrant
No fluid thrill
No shifting dullness
Auscultation::
Bowel sound heard
Respiratory system::
Inspection::
Shape of chest ::bilaterally symmetrical
No scars and sinus on Chest
No drooping of shoulder
Palpation::
Inspectory findings confirmed
Apex beat felt at5th IC space medial to midclavicular line
Percussion;;
Dull note on infrascapular area
Auscultation::
Mild Crepts heard in infrascapular area
Cvs:::
S1,s2 heard
No murmurs
No thrill
CNS....
Conscious
Speech normal
Neck stiffness.no
Kernigs sign.no
Sensory system:intact
Motor system:::
Reflexes..normal
Power of LL,uL...5/5
Investigations::
Comple.blood picture...
HB..11.3gm/dl
TLc.30000cells/mm3
Platelets::2.65lqakhs
RFt..
Urea..73mg/dl
Creatinine.1.7mg/dl
Na..137meq
K.4.2
Cl.95
LFt
Total bilirubin..2.55
Direct bilirubin.1.08
SGOT.41
SGPT.37
ALP..1022 Totalnprotien.5.9
Total albumin.1.72
A/g.0.42
RBS.122mg/dl
ECG:
Ultrasound abdomen.
1.liver abscess with hepatomegaly
2.raised echogenicity of b/l kidneys
on 12/01/2022
4pm..mild ascites detected
Provisional diagnosis:::
Abdominal pain
Liver abscess
Management::
Inj.ceftriaxone 1g /iv/bd
Inj Metrogyl 750mg
Inj.tramadol
Inj.pan 40 od
Inj.zofer
Intravenous fluids NS,RL ,DNS
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