63Y/M with right sided abdomen pain

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A 62 year old male patient , Carpenter by occupation came with complaints of Right sided abdomen pain ( 4 days back ) with diffuse chest pain 

History of presenting illness 

The patient was apparently alright r days back then he developed on and off right sides abdomen pain which was  not associated with vomiting / loose stools 

Relieved on taking medication 

 

A day before yersterday morning around 3 am patient have a pain in right side abdomen not relieved on medication radiating to back and right shoulder and right upper limb it was associated with one episode of vomiting not associated with sweating heaviness in chest 

Past history 

Not a known case of Hypertension , diabetes , asthma , TB , epilepsy. 

The patient had a tooth extraction 1 month back because of tooth pain he took some bland and smooth diet  . he decreased food in take from 4 days back because the patient experiencing  more pain in abdomen after taking food 

Personal history 

Diet - mixed

Appetite - normal 

Sleep - disturbed ( because of pain)

Bowel and bladder - regular 

Addictions -  takes alcohol daily 

Chronic alcoholic - takes 90 - 180 ml per day, some times skips ( rarely) since >20 years 

 Chronic smoker also - takes 1 pack( 10 - 12) of cigarettes/ bidi per day since > 20 years 

Family history

No significant family history

General physical examination 

Patient was conscious , coherent , co-operative , moderately built and nourished , well oriented to time place and person

 Pallor - present

 Icterus - absent

 Cyanosis - absent

 Clubbing - absent

 Lymphadennopathy absent

 Edema - absent

 

Vitals 

Systemic Examination  

Abdomen examination : 

Inspection - abdomen was slightly distended , no engorged veins , scars sinuses

 - umbilicus : central 

Palpation - the right hypochondrium was very tender and resistance was felt 

And the patient was not allowing to palpate the abdomen because of the pain .

  

Auscultation - bowel sounds was heard 

 CVS : S1 , S2 heard no murmurs 

Respiratory system - trachea was central , bilateral symmetrical expansion of chest was seen , normal bronchial vesicular sounds are heard , no stridor or crepitus 

CNS examination 

No focal neurological deficits  

Investigations 

USG 

On USG 2 calculi noted on gall bladder of size 12 mm each

Gall bladder was thickened 

CBP - HB :- 13.5 

           TLC :- 13,600 cells / DL

          Platelets :- 1.83 lacks 

CUE- 

       Pus cells :- 2 - 3 cells 

  

LFT -

       TB :- 1.54

       DB :- 0.88

    SGOT:- 37

    SGPT:- 10

     ALP:- 144

Albumin:- 2.9

RFT-

    S. Creatinine :- 1.1

       Na+ :- 133

       K+ :- 4.1

       Cl - :- 102

   Bloodurea - 23

 

RBS - 96 mg / DL

Troponin :- negative 

Serum Mg+2 :- 2.1

  

Diagnosis : 

ACUTE CHOLECYSTITIS with CHOLELITHIASIS .

Treatment 

After admission the patient was diagnosed with hypertension 

Patient was advice's not to take food till further orders 

INJ NS

       RL             } 75ml/hr

       DNS 

INJ TAXIM 1mg /IV / BD

INJ tramadol 1 ampule / 100ml

INJ zofer 4mg /IV/OD

INJ PAN 40mg/ IV/OD

INJ AMIKACIN 500mg IV BD

INJ METROGYL 100ml /IV / TID

Adviced to give

INJ PARACETAMOL 1 gm IV sos( if temp > 101° F)