A 35 year old male came with the chief complaints of pain in the right side of the flank

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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 and comprehending clinical data including history,clinical finding investigations and come up with a diagnosis and treatment plan.

A 35 year old male carpenter by occupation andresident of munugooru came to the OPD with the chief complaints of pain in the right side of the flank since 5 days.

HISTORY OF PRESENTING ILLNESS 

Patient is apparently asymptomatic 5 days back then he developed pain in the right flank since 5days that was sudden in onset and not progressive. Pain is severe and not radiating type.

Pain is associated with fever that is without chills and rigors and came to normal 2 days back after the medication.

It is also associated with generalised weakness of the body.

There is complaint of cough dry cough not associated with sputum.

The patient also complains of acidity, indigestion which increased with oil food intake.

There is no history of nausea and vomiting.

There is no history of weight loss.

There is no history of breathlessness.

HISTORY OF PAST ILLNESS 

There are no similar complaints in the past.

The patient suffered with ulcers of stomach and acidity before 10-12 years and received some medication and does not remember which he used for nearly 1month and discontinued.

The patient is not a known case of hypertension, diabetes, asthma , coronary artery disease.

DRUG HISTORY OR TREATMENT HISTORY 

he was under some medication 10-12 years back for acidity and ulcers of stomach.

FAMILY HISTORY 

There is no significant family history.

PERSONAL HISTORY 

Diet:- mixed

Appetite:- decreased since 5 days

Sleep:- disturbed due to pain.

Bowel movements :-decreased 

Bladder movements:-regular

Addictions :- daily intake of alcohol (90ml).

GENERAL EXAMINATION 

I examined the patient after taking the consent in a well light room.

Patient is conscious coherent and cooperative , moderately built and moderately nourished.

Pallor , cyanosis , clubbing , generalised lymphadenopathy and pedal edema is not seen.

Mild icterus is seen.

Vitals

Temperature :- afebrile

Pulse rate:-78bpm

Respiratory rate :-14cpm

Blood pressure :-130/80 mm of hg.

SYSTEMIC EXAMINATION 

R..S:- chest is bilaterally symmetrical, elliptical in shape.

     Trachea is central.

     Bilateral air entry is present , vesicular breath sounds are heard.

CVS:- s1, s2 heard , no murmurs heard.

C.N.S:- no focal neurological deficits.

Cranial nerves are intact.

Reflexes are normal

                

  Per abdomen:

Inspection:- symmetrical 

            There are no visible scars and visible pulsations.

Palpation:- soft and pain is elicited in the right hypochondrium.

                  No organomegaly appreciated.

Auscultation:- bowel sounds are heard.

INVESTIGATIONS 

CBP, ESR, Blood culture, LFT, USG.

 

PROVISIONAL DIAGNOSIS 

Liver abscess (with type 1 fatty liver)with cholilithiasis . 

MANAGEMENT 

 

Piptaz.INJ (4.5g)i.v /tid 

Metrogyl.INJ (500mg) I.v/ tid

I.v fluids n.s or r.l at 100 ml per hour.

Optineurin.INJ 1 ampoule in 100 ml of n.s I.v for over 30 mins.

Zofer.INJ (4mg) I.v /s.o.s