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
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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