1601006034 LONG CASE

 

1601006034 ; LONG CASE

    This is an online E log  to discuss our patient's  health data shared after taking his/her/guardian's signed informed consent. 

    Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

  This E log also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.



      A 61 year old gentleman who is resident of Kangaal ,shepherd by  occupation came with chief complaints of ,
•Pain in the abdomen since 10 days.
•Fever since  2 days.

HISTORY OF PRESENT ILLNESS:

    Patient was apparently asymptomatic 10 days ago ,then he developed

•Pain in abdomen :-
   - since  10 days
   - Diffuse and moderate
   - Insidious in onset 
   - Gradually Progressive
   - Dragging type 
   - Associated with shortness of breath 
   - Not radiating 
   - No diurnal variations
   - Relieved by sleeping sideways 

•Fever :-
  - Since 2 days 
  - Low grade 
  - Continous
  - Associated with chills and rigor 
  - Relieved on taking medication.


No History of Nausea,  Vomitings , Loose stools, flatulence,loss of weight , decreased urine output, dysuria.

    
PAST HISTORY:
-He had yellowish discoloration of eyes 6 months ago.
- No history of diabetes mellitus, hypertension, tuberculosis, epilepsy,asthma.

PERSONAL HISTORY:
•Mixed diet. 
•Appetite is  adequate.
•Sleep is adequate.
•Bowel movements are irregular as he is constipated.
•Bladder movements are regular.
•He is a chronic alcoholic takes 90ml/day since 30 yrs.
•He is a chronic smoker and takes 20 beedis/day since 30 yrs.

FAMILY HISTORY:
-Not significant.

TREATMENT HISTORY:
Took medication in local hospital 6 months back for jaundice.

ON GENERAL EXAMINATION,

-The patient is conscious, coherent and cooperative.
- He is well oriented to time, place and person.
- He is moderately built and moderately nourished.
-Examination was done after taking proper consent & in a well lit room after adequate exposure. 

▪︎Vitals :-
- Temperature = He is afebrile (at present)


- Pulse = 84 beats per minute, regular, normal in volume and character.

- Blood pressure = 120/70 mm of Hg

- Respiratory rate = 22 cycles per minute.

-Sp O2 :93% at room air

- JVP is normal

-Bulbar conjunctiva of left and right eye are yellow in color.




-Bilateral pitting type of pedal edema extending upto the level of ankle region.


- There is no Pallor, Clubbing, Cyanosis, Koilobyhia ,Generalized lymphadenopathy.

Local examination
Oral cavity : brown staining of teeth

GASTROINTESTINAL EXAMINATION :

■On Inspection,

•Anterior abdominal wall
- Abdomen is symmetrically distended with full flanks
-Umblicus is below the midposition between xiphisternum and pubic symphysis, Slightly everted with horizontal Slit .



- Abdomen skin is smooth and shiny
-All the quadrants are equally moving with respiration
-No venous prominence when examined both on sitting and standing position.
-No scars ,ulcers ,visible pulsations.
- No Scratch marks on the abdomen.
-No hernial swellings with and without cough impulse

• Posterior abdominal wall,
No scars , swellings, pulsations

■On palpation,

•Superficial palpation ,
- Localised tenderness in the right hypochondrium
- elastic consistency
- No rise in temperature,guarding and rigidity,thrills.

•Deep palpation,
-  Liver is  tender ,smooth ,firm , regular margin, moving with respiration.
- Spleen , kidneys , urinary bladder are not palable
-Abdominal girth is 84 cms


■On Percussion,
Liver span - 16 cms 
No shifting dullness .

■On auscultation,
Bowel sounds are heard 
No venous hum,bruit, friction rub.


RESPIRATORY EXAMINATION

■Upper respiratory tract examination -

•Nose: No deviated nasal septum, No nasal polyps
•Pharynx : no post nasal drip , congestion

▪︎Inspection;
•Shape of Chest is symmetrical ,Elliptical
•Trachea appears to be Central 
•Movements of chest equal on the both sides
•No Visible Pulsations, Swellings, Engroged Veins, Scars & Sinuses
•No signs of use of accessory muscles of respiration.
•No spinal deformities

▪︎Palpation;
- No local rise of temperature
- Trachea Central
- Respiratory movements are normal
- Chest Expansion 5cm (from 80-85cm)
- Transverse diameter 29cm
 -AP diameter 24cm
- Vocal fermitus Decreased on Right side lower region
- Apex beat is palpable in 5th intercoastal space ,1 cm medial to mid clavicular line
- No palpable lymph Nodes

▪︎Percussion;
✓Direct : resonant over clavicular, sternum.
✓Indirect :
   ✓Anterior.              Right.                 Left.
Supraclavicular:    Resonant.       Resonant   Infraclavicular:      Resonant.      Resonant
•Stony dull note on the right seventh intercostal space 
• Resonant note in second to sixth right intercostal space 
• Resonant note from second to sixth left intercostal space 
✓ Lateral chest wall 
 Dull note in the right  InfraAxillary region
✓Posterior:                Right         Left.
Suprascapular:    Resonant.    Resonant
Interscapular:      Resonant      resonant
Infrascapular:       Dull .             Resonant

 ▪︎Auscultation:

                                       Right.         Left
•Supraclavicular.        Normal.    Normal
• Infraclavicular.         Normal.    Normal
• Mammary                 Normal.    Normal
•InfraMammary.      Decreased.   Normal
• InfraAxillary.          Decreased.   Normal
• suprascapular.       Normal.        Normal
• Infra Scapular.      Decreased   Normal
• Interscapular.         Normal.       Normal

CVS
Normal S1 S2 heard
No murmurs
Apex beat felt on 5th intercostal space

CNS
No focal deficits seen 

✓INVESTIGATIONS :
Complete blood picture





Complete urine examination




Liver function test 




Ultrasound Abdomen





Aspiration of liver abcess 





Pleural fluid examination






Pleural tap




 Chest X-ray 




ABDOMEN X-RAY





ECG


 Rate : 100bpm
Regular
 Low voltage QRS complexes in L2 , AvF , V1
P waves T waves not visible in AvL



TREATMENT :-
1.INJ.MEROPENAM 500mg I.V ,BD
2.Inj.metrogyl 750mg I.V TID
3.Inj .pantop 40mg I.V,twice daily
4.Tab.Lasix 40 mg orally once daily
5 Tab.doxycycline 100mg oral twice daily
6.Tab.Linezoid 600mg per orally twice daily
7.Syrup lactulose 15 ml orally twice daily
8 Inj Vit.K 1 ampoule in 20ml .Normal saline I.V once daily

PROVISIONAL DIAGNOSIS :
Multiple  pyogenic liver Abcess with right side pleural effusion.

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