60YR OLD MALE WITH PAIN ABDOMEN AS CHIEF COMPLAINT

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CASE : 60 year old male, storyteller by occupation, resident of Nakrekal came to OPD with chief complaints of pain abdomen since 6 days.

HISTORY OF PRESENT ILLNESS :

. The patient was apparently asymptomatic 6 days ago, then he developed colicky type of pain in the right upper quadrant of abdomen which was insidious in onset and continous in nature, and radiating to back. 

. No aggravating or relieving factors. 

History of decreased urine output to which catheterisation was done. 

No history of fever with chills, vomitings, loose stools, cough, chest pain, shortness of breath. 

PAST HISTORY :

- No similar complaints in the past. 

- He is a known case of Diabetes since 6yrs and is on medication ( insulin ).

- Right 2nd and 3rd toes are amputated due to gangrene formation. 

- Not a known case of hypertension, asthma, epilepsy, TB. 

FAMILY HISTORY :

Not significant. 

PERSONAL HISTORY :

Diet - Mixed

Appetite - Normal

Sleep - Adequate 

Bowel and bladder movements - Regular 

Addictions - chronic smoker since 30yrs.

GENERAL EXAMINATION :

Patient was conscious, coherent and cooperative. 

Moderately built and nourished. 

No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, pedal edema. 

VITALS :

Temperature - Afebrile

Pulse rate - 91bpm

Respiratory rate - 15cpm

Blood pressure - 150/100mm Hg measured at 11.30am on 8th March 2021.

SYSTEMIC EXAMINATION :

Inspection :

. Shape of the abdomen normal. 

. Umbilicus inverted. 

. All the quadrants are moving equally on respiration. 

. No visible peristalsis. 

. No dilated veins are seen. 

Palpation :

. No local rise of temperature. 

. Tenderness noted in right hypochondrium. 

. Murphy's sign positive. 

. Spleen not palpable. 

Auscultation :

. Bowel sounds are heard. 

Following is the analysis in my case :

Anatomical location :

Liver, gallbladder, renal. 

Etiology :

Chronic smoker since 30yrs.

Investigations done :

CBP, LFT, RFT, USG ABDOMEN AND PELVIS. 

Positive findings from investigations :

USG Impression - 

LFT :

RFT :

Provisional diagnosis : 

Cholelithiasis.

Treatment :

Analgesics. 

Pantop 40mg bd. 

Continue insulin.