SHORT CASE 1
A 60 years old female presented to the casualty with complaints of fever associated with chills and abdominal pain.
CHIEF COMPLAINTs
➤Fever for the past 6 days.
➤Pain abdomen for the past 3 days
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 6 days ago after which she developed high
grade fever associated with chills, insidious in onset, progressive, not subsiding
with medication, continuous type
Pain abdomen , sudden in onset, pricking type, in the epigastrium
and right hypochondrium which gets aggravated on right lateral position and
relieved with sitting posture, associated with nausea and reduced appetite, no
association with intake of fatty food
No complaints of burning micturition.
No complaints of cough, cold or shortness of breath.
No complaints of heartburn or flatulence.
No complaints of heamatemesis or maleana.
No complaints of dysphagia.
No complaints of constipation or diarrhoea.
No history of yellowish discolouration of eyes or high coloured urine.
No history of weight loss
No history of any blood transfusion
No history of any high risk behaviour
HISTORY OF PAST ILLNESS
Not a known case of hypertension, diabetes, bronchial asthma, epilepsy.
No history of similar complaints in the past.
DRUG HISTORY
➤No significant drug history or intake of toxins.
PERSONAL HISTORY
➤Occupation: Daily waged labor working in Cotton fields.
➤Patient is married
➤Patient takes mixed diet but has a decreased appetite.
➤Bowel and bladder movement is normal and regular.
➤occasional Alcoholic , non smoker.
- sound sleep
FAMILY HISTORY
➤No significant family history.
MENSTRUAL HISTORY:
G 3 P 4 L 4 A 0
Attained menarche at the age of 20 years, with good flow and volume.
Attained menopause at age of 42 years.
SUMMARY:
60 year old female with high grade fever and abdominal pain confined to
right upper quadrant ,acute in onset, without any alcohol history .
Possibly case of
1) Acute Liver injury (?infective etiology)
2)Acute Cholecystitis.
GENERAL EXAMINATION
Patient is well built, well nourished.
➤Pallor : Not seen
➤Icterus : Not seen
➤Cyanosis : Not seen
➤Clubbing : Not seen
➤Lymphadenopathy : Not seen
➤Edema : Not seen
- No signs of chronic liver cell failure
- No signs of nutritional deficiency.
VITALS
➤Temperature : 101℉
➤PR : 108 beats per minute
➤BP : 100/70 mmHg
➤RR : 24 cycles per minute
➤SpO2 : 95% in room air
➤Blood Sugar (random) : 100mg/dl
SYSTEMIC EXAMINATION
ABDOMINAL EXAMINATION
INSPECTION
➤Shape - Scaphoid, with no distention.
➤Umbilicus - Inverted
➤Equal symmetrical movements in all the quadrants with respiration.
➤No visible pulsation,peristalsis, dilated veins and localized swellings.
PALPATION
➤SUPERICIAL :Local rise of temperature in right hypochondrium with tenderness
and localised guarding and rigidity.
➤ DEEP : Mild enlargement of liver, regular smooth surface , rounded
edges soft in consistency, tender, moving with
respiration non pulsatile
➤No splenomegaly
➤Abdominal girth : 78cms.
➤xiphesternum to umbilicus distance was equal to umbilicus to pubic distance.
PERCUSSION
➤Hepatomegaly : liver span of 16 cms with 4 cms extending
below the costal margin
➤Fluid thrill and shifting dullness absent
➤puddle sign absent
➤Traubes space : resonant
AUSCULTATION
➤ Bowel sounds present.
➤No bruit or venous hum.
NO LOCAL LYMPHADENOPATHY
PER VAGINAL AND PER RECTAL EXAMINATION : NAD
CARDIOVASCULAR SYSTEM EXAMINATION
➤s1 and s2 heard
➤Thrills absent.,
➤No cardiac murmurs
RESPIRATORY SYSTEM
➤Normal vesicular breath sounds heard.
➤Bilateral air entry present
CENTRAL NERVOUS SYSTEM EXAMINATION
➤Conscious and coherent
PROVISIONAL DIAGNOSIS :
ACUTE HEPATITIS (? INFECTIVE)
INVESTIGATIONS :
DAY 1
USG ABDOMEN
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USG REPORT IMPRESSION- Multiple liver abscess with largest measuring 5*5 cms in the 7th segment of liver , with 40 to 50% of liquefaction , hepatomegaly with liver span of 18.5 cms. CT SCAN   |
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