1801006111 SHORT CASE
1801006111 SHORT CASE
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Case discussion.
A 56 year old female came with c/o pain abdome since 10days
fever and generalised weaknesses since 2days.
HISTORY OF PRESENTING ILLNESS :
Patient was apparently alright 10 days back later she developed abdominal pain which was sudden in onset and rapid progressive. The pain was of a dull and persistent type radiating to the right shoulder and back. There were no aggregating and relieving factors. then she had fever for 3 days which is low grade, intermittent, associated with chills and rigors
H/o Nausea present .
No h/o vomitings, loose stools.
No orthoponea.
No PND, previous infections.
No h/o hemetemesis,jaundice , abdominal distension and weight loss.
PAST HISTORY :
No similar complaints in the past.
K/c/o HTN since 1 year on TELMA H 40/12.5
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.
GENERAL EXAMINATION :
pt is c/c/c
pallor present
Icterus- absent
Clubbing- absent
Cyanosis- absent
Lymphadenopathy- no palpable lymph nodes
Edema- pitting type edema present over the extremities of the lower limb .
VITALS
BP-90/60
PR-92bpm
RR: 22
Spo2 -97% @ RA
GRBS: 169mg/dl
SYSTEMIC EXAMINATION :
ORAL CAVITY: : lips, buccal mucosa, teeth, tongue, palate, tonsils, posterior pharyngeal wall normal and hygiene maintained.
RS-bilateral air entry present
Normal vesicular breath sounds heard
CVS -S1 S2 heard
No murmurs
CNS: No focal neurological deficits.
P/A :
Inspection:
Shape scaphoid and distended uniformly
Flanks are free and full
Umbilicus central and inverted
Skin on abdomen smooth with no visible veins and stretch marks
Murphy's sign positive.
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 heard.
On 14/3/23
Abscess drained
PROVISIONAL DIAGNOSIS :
Could be acute cholecystitis
Acute viral hepatitis
Acute cholangitis
As there is tenderness in Right hypochondrium.
INVESTIGATIONS :
CXR PA VIEW
USG Abdomen
USG buttock
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.
FINAL DIAGNOSIS :
Acute Cholelithiasis with gallbladder sludge.
With grade II fatty liver with hepatomegaly with HTN since 1 year
Fever secondary to L gluteal abscess
With AKI(prerenal)
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/od
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