1601006113 LONG CASE

 

1601006113 final exam long case



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A 61 year old gentleman who is resident of Kangaal ,shepherd by occupation came with complaints of pain in abdomen from 10days,Fever from 2 days

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 10 days ago, then he developed
  • Pain in abdomen - since 10 days which was insidious in onset, gradually progressive, diffuse, non radiating and  dragging type of pain which was relieved while sleeping on his right side.No H/O diurnal variation.
  • Fever - since 2 days which was a  low grade, continuous fever associated with chills and rigor. It was relieved on taking medication.
  • No History of nausea, vomiting, loose stools, flatulence, loss of weight, decreased urine output, dysuria.
PAST HISTORY:
  • He had yellowish discolouration of eyes 6 months ago.
  • No history of diabetes mellitus, hypertension, tuberculosis, epilepsy,asthma.
PERSONAL HISTORY:
  • Mixed diet
  • Appetite is normal
  • Sleep adequate
  • Bowel movements are irregular as he is constipated
  • 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.

GENERAL EXAMINATION:
  • Examination was done after taking proper consent & in a well lit room after adequate exposure.
  • The patient is conscious, coherent and cooperative with well orientation  to time, place and person 
  • He is moderately built and moderately nourished.
  • Icterus is present in bulbar conjunctiva of both eyes 
  • Bipedal edema ,which is pitting type upto the level of ankle region
                               
  • There is no pallor, clubbing, cyanosis, koilonychia, generalised lymphadenopathy.
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 in right arm in supine position
  • Respiratory rate = 22 cycles per minute, abdominothoracic breathing
  • Sp O2 :93% at room air
LOCAL EXAMINATION: Patient has brown staining of teeth

SYSTEMIC EXAMINATION:

A)  GASTROINTESTINAL EXAMINATION:
     1) Inspection:
a) 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 
b) Posterior abdominal wall: No scars , swellings, pulsations

    2) Palpation: 
a) Superficial palpation:
  • Localised tenderness in the right hypochondrium
  • elastic consistency
  • No rise in temperature, guarding and rigidity, thrills 
  • No palpable lymphnodes 
b) Deep palpation,
  • Liver is tender, smooth, firm, regular margin, moving with respiration.
  • Spleen, kidneys, urinary bladder are not palpable
  • Abdominal girth is 84 cms
    3) Percussion:
  • Liver span - 16 cms 
  • No shifting dullness .
  • No fluid thrill 
   4) Auscultation,
  • Bowel sounds are heard  
  • No venous hum,bruit, friction rub.

B) RESPIRATORY EXAMINATION:
   1) Inspection:
  • Upper respiratory tract examination - Brown staining on teeth, no deviated nasal septum, No nasal polyps, no post nasal drip
  • Chest is symmetrical and elliptical in shape
  • Trachea appears to be Central 
  • Movements of chest with respiration is 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
  2) Palpation:
  • All the inspectery findings are verified 
  • No local rise of temperature
  • Trachea Central
  • Respiratory movements are normal
  • Chest Expansion 5cm (from 80-85cm)
  • Transverse diameter 29cm and 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
   3) Percussion;
                > Anterior chest wall
                                                                                         Right.                                    Left.
  • Supraclavicular                                Resonant.                              Resonant 
  • Infraclavicular                                   Resonant.                             Resonant
  • 2nd to 6th inter coastal spaces        Resonant.                              Resonant
  • 7th inter coastal space                     Stony dull.                             Resonant
                > Lateral chest wall                  : Dull note in the right InfraAxillary region
                > Posterior chest wall               : 
                                                             
                                                                                         Right                                    Left.
  • Suprascapular                                Resonant.                            Resonant
  • Interscapular                                  Resonant.                            Resonant
  • Infrascapular                                     Dull                                   Resonant
    4) Auscultation:
                                                                              Right.                                         Left
  • Supraclavicular                                Normal                                       Normal
  • Infraclavicular                                   Normal                                      Normal
  • Mammary                                         Normal                                      Normal
  • Inframammary                                Decreased                                  Normal
  • Infraaxillary                                     Decreased                                  Normal
  • Suprascapular                                  Normal                                       Normal
  • Interscapular                                    Normal                                       Normal
  • Infrascapular                                  Decreased                                   Normal

C) Cardiovascular system examination:
  • Normal S1 S2 heard
  • No murmurs
  • Apex beat felt on 5th intercostal space

D) Central Nervous system examination:
  • No focal deficits seen 
INVESTIGATIONS:
 1) Complete blood picture

2) Complete urine examination

3) Liver function test:         

4) Ultrasound Abdomen:

5) Aspiration of liver abscess: 

6) Pleural fluid examination:




7) Pleural tap:

 


8) Chest X-ray:




9) Abdominal X-ray:






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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