Skip to main content

55 yr old male with yellowish discolouration, fever, loss of appetite and pain in abdomen

This is a case of 55 year old male who is construction worker(floor tile worker) by occupation and resident of olugonda of Nalgonda district who came with chief complaints of 


- YELLOWISH DISCOLOURATION OF EYE SINCE 1 MONTH.

-FEVER SINCE 1 MONTH.

-LOSS OF APPETITE SINCE 20 days.

-PAIN IN THE ABDOMEN SINCE 20 days.


HISTORY OF PRESENTING ILLNESS:


Patient was apparently asymptomatic a month ago then he noticed yellowish discolouration of eye for which he used HERBAL MEDICINE and then he complained of fever which was low grade and continuous type not associated with chills and rigours.

The patient later developed pain abdomen which was insidious in onset and gradually progressive. He localised the pain to his right upper quadrant. It was sharp in nature non radiating. There are no aggravating and relieving factors. 

History of decreased appetite from 1 month.

History of itching over the legs since 1 month which was increased at evenings and night.

No history of loose stools, nausea, vomiting, headache, dizziness, burning micturition.

No history of Malena, constipation, abdominal distension and haemetemesis .

PAST HISTORY:


Patient is a known case of PULMONARY TUBERCULOSIS 25 years ago for which he used medication for 3 months.
Appendectomy 25 years back.

Not a known case of DM, HTN, CVA, CAD, Thyroid disorders, Asthma and epilepsy.

PERSONAL HISTORY:


Daily routine: He wakes up at 5 in the morning and freshens up. Have tea at 8 AM and goes to work by 9 in the morning. He takes lunch at 1:30 PM. Around 5 PM he comes back to his house.
 
He has dinner by 8 PM and goes to bed at 9:30 PM.


DIET: MIXED.

APPETITE: DECREASED SINCE 20 DAYS.

SLEEP: ADEQUATE.

BOWEL AND BLADDER: IRREGULAR 
                           (once in 3 days and watery since 10 days)


ADDICTIONS: Alcohol since 35 years(180ML every day) and chews tobacco from when he was 25 years old. Stopped drinking alcohol 2 months back.


FAMILY HISTORY:

Not significant.


CLINICAL EXAMINATION:

GENERAL EXAMINATION:


I have examined the patient after taken prior consent and informing the patient. The examination was done in both supine and sitting position in a well lit room. 

The patient was conscious coherent and cooperative. Well oriented to time place and person. Well built and nourished.


VITALS: BP:110/70mmHg
                 RR: 16 cycles/ min
                 PULSE RATE: 90 beats per min
                 Temp: 100 F




PALLOR: ABSENT.

ICTERUS: PRESENT.








CYANOSIS: ABSENT 

CLUBBING: ABSENT 

LYMPHADENOPATHY: NO

EDEMA: ABSENT.







SYSTEMATIC EXAMINATION:



1) PER ABDOMEN:

INSPECTION:
-Shape of abdomen: flat 
-Umbilicus: inverted
-Presence of appendectomy scar
-All quadrants are moving equally with respiration
-No engorged veins
- skin over the abdomen is smooth.




PALPATION:
-No local rise of temperature 
- diffuse tenderness over the abdomen 
-No Rebound tenderness 
-No guarding rigidity
- liver not palpable 
- spleen not palpable 
Abdominal girth: 89 cm

PERCUSSION:
Shifting dullness - absent 
No fluid thrill
Liver span - 9 cm
Liver dullness is not heard at 5th intercostal space.

AUSCULTATION:
diminished bowel sounds 

2) CARDIOVASCULAR:
Inspection: 
apex beat :5th ICS half inch medial to midclavicular line
Palpation:
inspectory findings confirmed, No thrills or parasternal heave
Auscultation: S1 , S2 heard and no murmurs 

3) RESPIRATORY SYSTEM:

INSPECTION:
Shape of chest:Bilaterally symmetrical, Elliptical in shape
No visible chest deformities
No kyphoscoliosis,
Abdomino thoracic respiration, No irregular respiration
No tracheal shift
No dropping of shoulders, Spino scapular distance appears equal on both sides 
no sinuses and scars
No engorged veins

PALPATION
Inspectory findings confirmed by Palpation
Chest movements - normal
Chest expansion-equal on both sides


PERCUSSION:
Resonant note heard over all areas

AUSCULTATION:
- fine crepitations heard at right infra clavicular and  right mammary areas.
- Norma vesicular breath sounds heard in all other areas.
-Vocal resonance: normal in all areas

4) CNS:
Higher mental functions :intact
Cranial nerves intact
Motor examination:      R               L
 
Bulk.                              N               N
Tone.                              N               N
Power.                            N               N

Reflexes:
Biceps.                         2+              2+
Triceps.                        2+              2+
Supinator                     2+.             2+
Knee                             2+              2+
Ankle.                           2+.             2+

Sensory examination:Normal
No meningeal signs

PROVISIONAL DIAGNOSIS:

CHRONIC LIVER DISEASE? with HIV test reactive (Z +ve).
Hyponatremia under evaluation.

INVESTIGATIONS:

BLOOD UREA: Normal


RBS: 94mg/dL


SERUM ELECTROLYTES: Hyponatremia(128mEq/L)
                    

HbsAg-RAPID : NEGATIVE


Serum creatinine: Normal


Liver function tests: 

total bilirubin: increased (1.26mg/dL)
Direct bilirubin: increased (0.30mg/dL)
SGOT(AST): elevated (88 IU/L)
SGPT(ALT): elevated (72 IU/L)       
ALKALINE PHOSPHATASE: elevated ( 553 IU/L)
ALBUMIN: decreased (2.95g/dL)    


HIV rapid test: Reactive


Chest X-ray(PA VIEW):























Comments

Post a Comment

Popular posts from this blog

49 years old male with CHRONIC KIDNEY DISEASE associated with osteoarthritis of knee

chief complaints: A 49-yr-old patient came with OPD with chief complaints of  -bilateral knee pain and Lower bach ache since 2 months. -pedal edema since 1 week. -shortness of breath since 1week. -decreased appetite since 1 week. history of presenting illness: -Pt was apparently assymptomatic 2 months ago, then he devoleped B/L knee pain which was insidious in onset ,gradually progressive ,pain increase on work for which he used NSAID’s prescribed by local RMP for 15-30 days and stopped  -he devoleped pedal edema 1 week ago which was insidious in onset and initially restricted to below ankle then progressed above ankle level which is not relieving on rest and not associaed with fever -he devoleped grade II shortness of breath 1 week ago DAILY ROUTINE: Patient used to be a farmer by occupation but he stopped 2 montgs back due to increased knee pain and was mostly confined to his home ad surroundings. He wakes up at around 5:30 AM and freshens up. He will be having breakfast at ...
Post a Comment
Read more

79Y/M with recurrent CVA with aspiration pneumonia and seizures.

79 y/o male with Recurrent CVA and left hemiplegia with Aspiration pneumonia and seizures disorder COMPLAINTS AND DURATION: A 79 y/o male was brought to casuality with c/o cough since 20 days ,  fever since 10 days difficulty in swallowing and h/o Aspiration pneumonia since one month C/o altered sensorium since 3 days HOPI: Patient was apparently asymptomatic 20days back then  he developed cough insidious in onset and gradually progressive. PRODUCTIVE but patient is not able to spit it out. Difficulty in swallowing. H/o cough on intake of liquids.  H/o change of voice since 20 days, insidious, hoarse in character and   SLURRING OF SPEECH +present No h/o difficulty in breathing, breathlessness, hemoptysis  Fever since 10 days -high grade. O/e Chills and rigors + (38 spikes). N/h/o vomiting, chest pain, loose stools. 7 YEARS BACK:(2016) He developed  head ache at around   afternon 2pm  and followed by  vomtings  and  left hand it...
Post a Comment
Read more

A 60year old female with neck pain

This is a case of a 60year old female with the c hief complaints of -  Neck pain and headache since 5 years  HISTORY OF PRESENTING ILLNESS The patient was apparently asymptomatic 10 years ago. She then complained of back pain which is insidious in onset and gradually progressive. There are no aggravating or relieving factors. She then developed a head injury due to a heavy object (bottle gourd) falling on her head. 5 years ago she developed fever which was associated with pain in multiple joints and was diagnosed with Chikungunya. Following the episode the joint pains persisted and the  patient complained of pain in multiple joints which started in the fingers and wrist and progressed to all the joints. The pain in the joints is greater when she wakes up and is associated with stiffness. The stiffness is relieved on activity.  Her neck pain also started around 5 years ago and is associated with pain in the right nuchal and  occipital region and the right shoulde...
Post a Comment
Read more