50 YEAR OLD WITH ABDOMINAL PAIN
50 year old male with abdominal pain
Long case
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DATE OF ADMISSION:16/01/2023
Cheif complaint
50 year old male farmer by occupation came to opd with cheif complaint of abdominal pain since one month
History of present illness
Patient was apperantly asymptomatic 1 month back
When he developed pain in the abdomen in epigastric and right hypochondriac region which is squeezing in nature, non radiating type
The pain was increasing after consumption of food,and pain lasts for about 20 to 30 mins and then relieves on its own and also associated with abdominal bloating
He also complaints of non ulcer dyspepsia since 5 years
No history of shortness of breath
no history of vomiting,regurgitation,
No history of fever
No history of diarrhoea or constipation
No history of loss of appetite
No history of blood in stools
Past history
No similar complaints in the past
No history of hypertension, diabetes, cva,cad,asthma,tuberculosis, epilepsy
Personal history
Married
Farmer by occupation
Diet is mixed
Bladder ,Bowel movements normal
Sleep adequate
Addictions:chronic smoker since 20 years
He smokes almost 10 cigarettes per day
Also chews betel nut and tobacco 4 to 5 times a day
Occasional alcoholic since 30 years
No known history of allergy
Family history
No relevant family history
General examination
Patient was examined after taking consent
Patient is conscious, coherent, cooperative
Well oriented to time ,place and person
Well built,well nourished
No signs of pallor,icterus, cyanosis, clubbing, lymphadenopathy, oedema
Vitals
Temperature : afebrile
BP : 120/80 mm HG
Pulse rate : 78 / min
Resp.rate : 16 cpm
Grbs:103 mg/dl
Systemic examination
Inspection:oral cavity doesnt have any dental caries and there is presence of staining of teeth
Abdomen is scaphoid shaped
Umbilicus is centrally placed
No swelling of abdomen is seen
No scars are seen
No sinuses are seen
No engorged veins
Palpation
Palpation done in supine position
No local rise in Temperature
tenderness of abdomen
No palpable organs
No hepatomegaly and splenomegaly
No rigidity of abdomen
No palpable mass is present
Percussion
No fluid thrill
No shifting dullness
Tympanic note js heard
Auscultation
Bowel sounds are heard
Cvs examination
S1,s2 sounds are heard
No murmers
Cns
Conscious, coherent cooperative
Sensory and motor system normal
No neurological defects are seen
Respiratory system
Chest is bilaterally symmetical
Chest movements are equal on both sides on Respiration
No wheezing
No cough
No dyspnoea
Normal vesicular breath sounds
Investigations
Diagnosis :solitary liver absess
Treatment :
Tablet pan 40 mg po/od
Syrup: sucralfate10ml po/bd
