SHORT CASE
A 50 year old male patient with abdominal pain
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CHIEF COMPLAINT
A 50 year old male farmer by occupation came to casualty with chief complaint of abdominal pain since 1 month
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic one month back oand then developed pain on 4 dec abdominal pain on in right hypochondric region and epigastric region and and associated with pain and discomfort after having food
Pain episode :20 minutes
No history of shortness of breath
No history of vomiting
No history of diarrhoea
No history of loss of Apetite
No history of blood in stools
HISTORY OF PAST ILLNESS
No similar complaints in the past
No known Dm,tb,asthma,epilepsy ,HTN
FAMILY HISTORY
No significant family history
PERSONAL HISTORY
Diet:mixed
Apetite :normal
Bowel and bladder : regular
Sleep: adequate
Addictions: patient consumes alcohol occasionally (twice weekly 150ml)
Smokes cigarettes
Chews Khaini and betel leaf (4 times a day )
GENERAL EXAMINATION
No cyanosis , lymphadenopathy, edema
VITALS
Temperature:afrbrile
Blood pressure: 130/80mmhg
Pulse rate : 88bpm
Respiratory rate : 16pcm
SYSTEMIC EXAMINATION
ABDOMEN
INSPECTION
Shape of abdomen: scaphoid
Flanks : no flanks
No visible sinuses and scars are seen
No dilated veins
No bruits
PALPATION
No palpable mass
No rigidity Is felt
Liver and spleen not palpable
Hernial orifice: normal
PERCUSSION
tympanic note is heard
AUSCULTATION
Bowel sounds are heard
RESPIRATORY
Chest is bilaterally symmetrical
Trachea:centre
Normal vesicular breath sounds are heard
CVS
S1,S2 heard
No murmurs
No thrills
CNS
Speech is normal
Motor and sensory system:normal
Patient is conscious
Memory is intact
PROVISIONAL DIAGNOSIS
Solitary liver abscess
INVESTIGATIONS
TREATMENT
Tab pan 40mg po/od
Syrup: sucralfate 10ml po/bd
