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.