1601006076 LONG CASE
1601006076 - long case
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CASE:
Fever since 2 days
History of presenting illness:
•Patient was apparently asympomatic 7 days back and then he developed abdominal pain in the epigastrium ,which was insidious in onset and gradually progressive, dragging type and not associated with vomiting
•Patient has fever since 5 days which is low grade , not associated with chills and rigors, relieved by medication.
• associated with shortness of breath
• yellowish discolouration of eyes and skin since 3 months.
•No h/o vomiting, loose stools, palpitations,
And decreased urine output.
Past history:
•Similar complaint in the past 2 year back ,had pain in abdomen for which he was admitted in the hospital and got aspiration of fluid from the liver which was green in colour.
• Not a known case of diabetes, hypertension, asthma, tuberculosis, epilepsy
Family history : not relevant
Drug history:
Took medications for pain 2 years back
Personal history:
Takes mixed diet
Sleep adequate
Appetite decreased
Bowel and bladder movements are regular.
Patient is chronic alcoholic, takes 90 ml of whisky per day since 30 years
Smokes 20 beedies per day since 30 years.
General examination:
Patient is conscious , coherent and cooperative and oriented to place, time and person
Moderately built and moderately nourished
Icterus - present
Edema - bipedal edema , pitting type present up to ankles
No pallor, cyanosis, clubbing, lymphadenopathy
Vitals:
Temperature: febrile
BP : 120/80mmhg
RR:26 cpm
PR: 92bpm,regular rhythm , normal volume and charecter
Abdominal examination:
Inspection:
Shape of the abdomen - distended
No engorged veins
Hernial orfices are free
No scars
Palpation:
- 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 ,not able to insuate finger under the costal margin
- Spleen , kidneys , urinary bladder are not palable
-Abdominal girth is 84 cms
On Percussion,
Liver span -16cm
No shifting dullness,fluid thrill
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 Normal, Elliptical
•B/L Symmetrical
•Trachea appears to be Central (Trails sign -ve)
•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.
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 ,1.25 cms 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 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:
✓LFT
✓Diagnostic aspiration of liver: revealed pus sent for culture and sensitivity
✓Aspiration of peritoneal fluid: revealed clear watery fluid
✓ECG
Rate : 100bpm
Regular
Low voltage QRS complexes in L2 , AvF , V1
P waves T waves not visible in AvL
Left axis deviation
✓ HBsAg antigen
✓CBP
✓ dengue IgM positive
✓abdomen x Ray:
✓ ultrasound:
- multiple well defined heterogeneous lesions distributed in both the lobes of liver with poor liquifaction.
- mild ascites.
Provisional diagnosis:
multiple liver abscess with right sided pleural effusion
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
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