50 years old male patient with abdominal pain(Long Case)

50 year old male patient with abdominal pain.

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Date of admission: 16-01-2023.

Cheif complaint: A 50 year old male, farmer by occupation came to the opd with the chief complaints of abdominal pain since 1 month

History of present illness:-

Patient was apparently asymptomatic 1 month back, then he developed abdominal pain after consumption of food in epigastric region 

Squeezing type of pain, non radiating, increases after food consumption and after lifting heavy weights relieving on its own

Pain lasts for 30 minutes during the episode

No h/o weight loss

No h/o vomitings

No h/o diarrhoea or constipation 

No h/o loss of appetite 

No h/o fever

No h/o blood in stools

No h/o burning micturition

No h/o shortness of breath

No h/o regurgitation of food.

History of past illness: 

No similar complaints in the past.

N/k/c/o Hypertension, DM, Asthma, Epilepsy, CAD, TB.

Personal history:

-Diet - Mixed

-Appetite - normal

-Bowel and bladder movements- Regular

-Sleep- adequate.

-Addictions - Patient consumes alcohol occasionally , smokes cigarette -8-10 or a box full per day, chews khaini and betel leaf(pan) 3-4 times daily.

Family history:

-No significant family history.

General examination:

-Patient was examined after taking his consent.

-Patient was conscious, coherent, cooperative, well oriented to time place and person, well nourished and well built.

-Pallor- Absent

-Icterus- absent

-Clubbing- absent

-Cyanosis- absent

-Lymphadenopathy - absent

-Edema- absent.

Vitals:

-Temperature: afibrile

-Blood pressure:130/80mmhg

-Pulse rate:88 bpm.

-Respiratory rate:16 cpm.

Systemic examination:

Inspection:

-Abdomen:

-Shape of the abdomen- Scaphoid

-Flanks: flanks are free

-Umbilicus- centrally placed and inverted.

-Sinuses and scars- no visible sinuses and scars are seen.

-Dilated Veins- no visible veins 

-No visible peristalsis or no visible pulsations

-All quadrants moving equally on respiration

-Bruits: No

Palpation:

-Done in supine position with hands by side of the body.

-No tenderness or local rise in temperature.

-No rigidity is felt.

-No palpable mass

Hernial orifice:normal

-No organomegaly.

-liver: not palpable

-spleen: not palpable

Percussion:

-Tympanic note is heard all over the abdomen.

Auscultation:

- Bowel sounds are heard.

Respiratory examination:

-Chest is bilaterally symmetrical.

-Movements with respiration are equal on both the sides.

-Trachea appears to be in center.

-No kyphoscoliosis.

-Normal Vesicular breath sounds are heard.

Cardiovascular examination:

- Elliptical & bilaterally symmetrical chest

- Apex beat palpable at 5th intercostal space medial to midclavicular line 

- S1 , S2 heard

- No murmurs.

-no trills

CNS examination:

-No focal neurological deficets .

-Speech is normal.

-Memory is intact.

-cranial nerves:normal

-Motor and sensory system:normal

Provisional diagnosis:

Liver disease.

Gastritis

 Cholelithiasis

Investigations:

Ultrasound report-16-01-2023.

Hemogram- 17-01-2023.

Final diagnosis: liver abscess.

Treatment: T pan 40 mg po/od.