A 50 year old male with epigastric pain

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This is a case of a 50 year old male with complaints of fever since 5 days and epigastric pain since 4 days 

History of Presenting Illness

Patient was apparently asymptomatic 5 days ago. Then he developed fever. It lasted for a day and was associated with chills and rigours and subsided with antipyretics. Then later in the evening he developed epigastric pain after the fever subsided. Pain is in the epigastric and right hypochondriac region primarily, gradually progressive in onset, it is of a dragging type of pain, he says its radiating to his flanks and lower back. He has decreased appetite since 4 days and has not been passing stools. The pain is exacerbating when he has food. 

He also says he had shortness of breath of grade 2, two days back, but it has relieved now. No history of orthopnea or PND 

DAILY ROUTINE:

The patient wakes up at around 4 am and completes his daily morning activities. He is a labourer by occupation so he goes to work at 5 am and comes back home at 8 am to have food. Depending on the type of work he does that particular day, the time he comes home sometimes varies. At around 9:30 he goes back to work and doesn’t come back home at around 6 pm. He has food and sleeps by 9 pm. He consumes alcohol everyday regularly at 6 pm of 90 ml since the past 10-15 years. He also smokes one beedi a day since the past 30 years.

Events leading to the present day:
The patient as usual woke up and went to work. He said his work that day was spraying fruits with some chemicals. He came home around at 11 am that day to have food. He had rice and dahl and developed fever insidiously after eating. His fever subsided in the evening and then he developed epigastric pain. He has not been going to work since the past few days and is at home taking rest since the pain is so severe. No one else in the family had similar complaints.


Past history:

He has no similar complaints in the past. Not a k/c/o diabetes, hypertension
No history of blood transfusion.

General examination

Pallor: present
Icterus:present
Clubbing: absent
Cyanosis: absent
Lymphadenopathy: absent
Edema: absent

Vitals:

Temp: afebrile on time of examination 
BP 120/90
Heart rate 90 bpm
Resp Rate 18 /min 


















Abdominal examination:
Abdomen is obese
Soft 
Tenderness over epigastric and right hypochondriac region
Murphy’s sign: absent
No rebound tenderness, shifting tenderness
No organomegaly
No shifting dullness
No fluid thrill
Bowel sounds heard

Respiratory examination

I: Chest bilaterally symmetrical, all quadrants
moves equally with respiration
P: Trachea central, chest expansion normal
P: Resonant
A: B/l equal air entry
B/I VBS
no added sound

CVS examination:

I: No precordial buldge. Apical impulse
visible, Venous prominence
P: Apical impulse in 5th intercostal space, No palpebral pulsation.
A: S1 S2, No murmur

CNS: No focal neurological deficits

Investigations:







Differential Diagnosis:
 
Viral hepatitis
Liver abscess
Cholecystitis
Enteric fever
Pancreatitis presenting with epigastric pain



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