42year old male patient with abdominal pain ,shortness of breath and cough with sputum.
Date of admission: 11/1/23
January 18, 2023
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A 42 year old male patient, farmer by occupation, resident of Nalgonda, came to casuality with the cheif complaints of-
Fever since 3 days, Abdominal pain since 3 days, Shortness of breath since 2 days and Cough with sputum since 2 days.
History of present illness:-
Patient was apparently assymptomatic 3 days ago and then he developed fever which was sudden in onset, gradually progressive, high grade, associated with chills, rise of temperature during nights and subside by early morning.
Pain in the hypochondrium and epigastric region since 3 days which was sudden in onset, gradually progressive, non-radiating and dull-aching type of pain. No aggravating and relieving factors.
Shortness of breath(Grade 2) since 2 days and cough with expectoration since 2 days mucoid in consistency and also associated with chest pain.
Loss of appetite since 3 days
No history of loose stools, vomitings, weight loss.
No history of outside food intake
History of past illness:-
No history of similar complaints in the past.
Not a known case of diabetes, hypertension, tb, epilepsy, asthma.
Personal history:-
Diet :Mixed
Appetite:-Decreased
Sleep:-Adequate
Bladder and bowel movements:-Regular
Addictions :Chronic alcoholic(90ml) since 5 yrs and chronic smoking since 20 years(1 packet per day).
Drug and allergic history:-
No known relevant drug and allergic history
Family history:-
No significant family history.
General examination:-
Patient is conscious, coherent, cooperative and well oriented to time, place and person.
No Pallor ; Icterus; clubbing ;cyanosis ,Lymphadenopathy
No Malnutrition
Vitals:-
Temperature-98.6 F
Pulse rate-104 bpm
RR-30 cpm
BP-110/70 mm/hg
SYSTEMIC EXAMINATION:-
RESPIRATORY SYSTEM-
Inspection-
Chest
Shape-Normal
Trachea-Midline
No sinuses, scars ,dilated veins
Asymmetric chest expansion
Palpation-
Measurements-
Inspiration-30 cms
Expiration-29.5 cms
Difference-0.5 cms
Hemithorax-15 cms
Trachea-Midline
MOVEMENT OF CHEST:
RIGHT LEFT
SUPRACLAVICULAR :. SYM. SYM
MAMMARY:. SYM SYM
INFRAMAMMARY :. ASYM SYM
AXILLARY:. SYM. SYM
INFRA AXILLARY :. SYM. SYM
SUPRASCAPULAR :. SYM. SYM
SCAPULAR :. SYM SYM
INFRASCAPULAR:. ASYM. SYM
PERCUSSION-
Right. Left
SUPRACLAVICULAR :. Resonant (R) R
MAMMARY:. R R
INFRAMAMMARY :. R Dullness
AXILLARY:. R R
INFRA AXILLARY :. R R
SUPRASCAPULAR :. R R
SCAPULAR :. R R
INFRASCAPULAR:. R Dullness
RIGHT LEFT
Ascultation-
SUPRACLAVICULAR :. N N
MAMMARY:. N N
INFRAMAMMARY :. N vocal resonances decreased
AXILLARY:. N R
INFRA AXILLARY :. N N
SUPRASCAPULAR :. N N
SCAPULAR :. N N
INFRASCAPULAR:. Vocal resonance decreased
No added sounds
Abdomen examination-
Inspection-
Shape of the abdomen-Scaphoid
No abdominal distention visible
Umbilicus-Position-Midline
Shape-Inverted
No scars ,sinuses ,scratch marks ,puncture marks, dilated veins ,visible peristalsis
Palpation-
No organomegaly
Spleen-Non palpable
Percussion-
No fluid thrill.
Ascultation-
Bowel sounds heard 4/min
Oral examination:
Hyperpigmented gingiva
Plaque present
Calculus present
Tongue normal
No gingival enlargement
No halitosis
No Oral thrush
Provisional diagnosis:
Liver abscess with Pleural effusion
Investigations:
Temperature chart:
Heamogram
CUE
BLOOD UREA
SERUM ELECTROLYTES
SERUM CREATININE
Urine protein/creatinine ratio:
Random blood sugar
Fasting blood sugar
Post lunch blood sugar
HbA1c
Blood parasites
LFT
Chest - x ray
USG chest
USG abdomen
ECG
Colour doppler 2D echo
Treatment:-
IV Fluids NS RL @ 100 ml/hr
Inj. Monocef 2gm/IV/BD
Inj. Metrogyl 750mg/IV/TID
Inj. Pantop 40mg/IV/TID
Inj. Optineuron lamp 100ml NS/IV/OD
Inj. Thiamine 200mg in 100ml NS/IV/BD
Tab. Dolo 650mg PO/6th hourly
Inj. Neomol 1gm/IV/SOS
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