1601006069 long case
Hall ticket no : 1601006069
GENERAL MEDICINE LONG CASE
61 year old gentleman who is resident of kangaal,shepherd by occupation came with complaints of pain in abdomen since 10days,fever since 2days.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 10 days ago then he developed
1. Pain in abdomen
-since 10 days
-It is a diffuse type of pain not associated with
any vomiting and was progressive,dragging
type of pain associated with shortness of breath
- it was non radiating pain with no diurnal variations
- it was relieved by sleeping sideways.
2.Fever
-since 2 days,low grade ,continuous associated with chills and rigor ,relieved on taking medication
No History of Nausea, Vomiting Loose stools, Melena, decreased urine output, dysuria.
PAST HISTORY:
-He had yellowish discoloration of eyes 6 months ago.
- No history of diabetes mellitus, hypertension, tuberculosis, epilepsy.
PERSONAL HISTORY:
-mixed diet
-apetite normal
-His bowel movements are irregular as he is constipated.
- His bladder movements are regular.
-He is a chronic alcoholic takes 90ml/day since 30 yrs
- He is a chronic smoker and takes 20 bidis/day since 30 yrs.
FAMILY HISTORY: not significant.
TREATMENT HISTORY:
-took medication in local hospital 6 months back for jaundice.
GENERAL EXAMINATION:
- The patient is conscious,coherent, 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/ min, regular, normal in volume and character.
-Respiratory rate:26 cycles/min
-Blood Pressure:120/70 mm Hg
-Sp O2 :93% at room air
-Jvp is normal.
-Bulbar conjunctiva of left and right eye are yellow in color.
Bipedal edema ,pitting type,upto the level of ankle region.
There is no Pallor, Clubbing, Cyanosis, Generalized lymphadenopathy
LOCAL EXAMINATION:
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.
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 palpable.
-Abdominal girth is 84 cm
PERCUSSION
Liver span -16cm
No shifting dullness,fluid thrill
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, Engorged 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 fremitus Decreased on Right side lower region
- Apex beat is palpable in 5th intercostal 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
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
CVS
Normal S1 S2 heard
No murmur
CNS
No focal deficits seen
INVESTIGATIONS :
Complete blood picture
Ultrasound report
Aspiration of liver abscess:
Pleural fluid examination:
Abdominal xray
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 liver Abcsess with right side pleural effusion.
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