1801006102- short case

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I have 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

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

CONSENT WAS GIVEN BY BOTH PATIENT AND ATTENDERS

Case discussion:

A 56 year old female presented to the casualty with complaints of pain in abdomen since 10 days, fever and burning micturition since 2days. 

History of presenting illness

Patient was apparently asymptomatic 10 days back and later she developed abdominal pain which was sudden in onset and rapid in progression. The pain was of a dull and persistent type radiating to the right shoulder and back. There were no aggregating and relieving factors.

 There is history of (H/O) nausea, loss of appetite

There is no H/O vomitings, loose stools, abdominal rigidity. 

Two days ago she developed fever which was low grade, intermittent, associated with chills and rigors. 

Fever subsided on taking medication. 

There is no H/O vomitings, loose stools, previous infections. 

Past history 

No similar complaints in the past

Patient is diagnosed of Hypertension (HTN)

No H/O diabetes mellitus, epilepsy, tuberculosis, thyroidal illnesses, tuberculosis, maignancies, cardiovascular disease. 

No previous history of hospitalisation and surgeries. 

Personal history 

Diet- Mixed

Appetite- decreased 

Bowel and bladder- regular 

Sleep- adequate 

Addictions- consumes Toddy occasionally 

Family history - All 4 children ( 2 sons and 2 daughters ) diagnosed with HTN

Treatment history- Tab. Telmisartan 40mg daily. 

General examination- 

Consent of patient taken

Patient is conscious, coherent and cooperative. 

Well built and nourished 

Pallor- absent 

Icterus- absent 

Clubbing- absent 

Cyanosis- absent 

Lymphadenopathy- no palpable lymph nodes 

Edema- pitting type edema present over the extremities of the lower limb 

Temperature: 102°F

Pulse:74 beats/ minute 

Blood pressure: 110/70 mmHg 

Respiratory rate: 20 cycles/ minute 

Systemic examination 

ORAL CAVITY: lips, buccal mucosa, teeth, tongue, palate, tonsils, posterior pharyngeal wall normal and hygiene maintained 

ABDOMEN:

Inspection -

Shape scaphoid and distended uniformly

Flanks are free and full

Umbilicus central and everted 

Skin on abdomen smooth with no visible veins and stretch marks

No dilated veins

No visible peristalsis

Hernial orifices free

External genitalia normal and healthy

Palpation-

Tenderness present on the right hypochondriac region with no localised raise in temperature 

Liver- tender, non pulsatile swelling palpated in the right hypochondium 2cm below the right coastal margin which moves with respiration and is firm in consistency. Smooth surface felt with rounded edges. 

Spleen- non tender, unpalpable. 

Kidneys-non tender and unpalpable. 

No other palpable swellings

Percussion-

Resonant sound heard over the abdomen 

No fluid thrills

Dull note of liver heard upto 2cm from the coastal margin 

Auscultation- bowel sounds heard, normal aortic bruit heard, no venous hums or rubs 

LOCAL EXAMINATION 

Ulcer of 4x3 noted on the left gluteal region. 

Abscess drained 

Day 1

                

                                    Day 2

                                    Day 3

Day 4

                                       Day 5

 

Provisional Diagnosis: Grade 2 fatty liver with hepatomegaly, cholelitheasis with gall bladder sludge. Fever secondary to gluteal abscess

Investigations:

*complete blood picture 

Blood group B-ve

Haemoglobin 11.7

Total leukocyte count- 22,400

Red blood cell count- 3.8 

Platelet count- 5 lakhs

 

Blood urea- 58

Serum creatinine-1.9

Serum sodium-127

Serum potassium-3.4

Serum calcium-92

Thyroid profile

T3- 0.33

T4-10.46

TSH-3.30

Complete urine examination 

Clear urine

Acidic 

Sugars absent

Pus cells- 3-6

Epithelial cells 2-4

Chest x ray

ECG

Abdominal usg

Treatment:

1.NBM till furthur order

2.INJ PIPTAZ 2.25gm IV/TID

3.INJ METROGYL 500mg IV/TID

4.IV FLUIDS  1unit NS, RL, DNS @ 100ml/hr

5.INJ PAN 40mg IV/OD

6.INJ ZOFER 4mg IV/SOS

7.INJ NEOMOL 1gm IV/SOS

8.TAB PCM 650mg PO/TID

9.T CINOD 10mg po/o