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Name:- J. Lohith Varma
(1st Yr student- MD General Medicine)
35yr old male, carpenter, came to the medicine OPD with Pain Abdomen
(Right hypochondriac & Right lumbar Region)
Since 4 days.
HISTORY OF PRESENTING ILLNESS:
Patient was apparently alright 4 days ago then he had developed fever (high grade) associated with chills which relieved on medication, he had also developed Pain Abdomen (Rt.hypochondriac & Rt.lumbar Region) Since 4 days, which was not Radiating.
No h/o Vomiting and loose stools
No h/o Pedal oedema, Decreased urine output,
Shortness of breath
PAST HISTORY:
No similar complaints in the past. Patient is not a k/c/o DM,HTN,CVA,CVD,TB,Asthma.
PERSONAL HISTORY:
Diet is mixed
Appetite is good
Sleep is Adequate
Bowel & Bladder movements are Regular
No Known allergies
Patient is a Chronic Alcoholic (180ml/day)
FAMILY HISTORY:
No significant family history
GENERAL EXAMINATION:
Patient is conscious, coherent, cooperative.
Well oriented to time, place and person. Moderately built and moderately nourished.
There is no pallor, icterus, cyanosis, clubbing, lymphadenopathy and oedema.
Vitals
BP: 130/80mmHg
PR: 88 bpm
Temp: afebrile
RR: 22 cpm
GRBS: 142mg%
SYSTEMIC EXAMINATION:
CVS: S1 S2 present
No thrills / murmurs
RS: B/L Air Sounds Heard (Vesicular)
Position of trachea is central
No dyspnoea / wheeze
CNS: Patient is conscious
Normal speech
No neck stiffness
Glasgow scale 15/15
Reflexes -normal
Per Abdomen:
Shape -Rounded
Tenderness present in the Rt.Lumbar and art.hypochondriac region
with no Guarding or Rigidity
No palpable masses
No free fluids
No bruits
Liver and spleen are not plapable
Bowel sounds present
INVESTIGATIONS:
Haemogram:
Hb-12.6gm/dl
TLC- 15,300 cells/cumm
Neutrophils -65%
lymphocytes -20%
monocytes-10%
Eosinophils - 5%
PLT - 4.7 lakhs/cumm
RBC-3.72million/cumm
PCV - 36.7%
MCV-98.7
MCH -33.9
MCHC - 34.3
RDW-CV-12.9
DRW-SD-47.0
CUE
colour - Pale yellow
Appearance - Clear
Reaction - Acidic
sp. Gravity - 1.010
Albumin - Trace
Sugar -Nil
Bin salts - Nil
Bile Pigments - Nil
Epithelial cells-2-3
RBC-Nil
Crystals-Nil
Casts-Nil
RFT
B.Urea- 26mg/dl
S.Creatinine - 0.9mg/dl
LFT
Total bilirubin: 0.74mg/dl
Direct bilirubin: 0.17mg/dl
SGOT:17 IU/L
SGPT: 15IU/L
ALP: 75IU/L
Total proteins:6.6gm/dl
Albumin:3.1gm/dl
A/G ratio: 0.89
Serum Electrolytes
Sodium- 131 mEq/L
Potassium- 4.3 mEq/L
Chloride - 102 mEq/L
Calcium Ionized 1.06 mmol/L
Phosphorus- 3.4mg/dl
HbsAg- Negative
Anti HCV Antibodies- Non Reactive
Ultrasonography Abdomen:
- Grade 1 Fatty liver with mild hepatomegaly
- Evidence of 7*4cm Liver Abscess noted in segment 5 of liver with 10 % liquefaction
- Normal Right iliac fossa
- Evidence of few Hyper echoic foci noted in gallbladder, largest with 6-7mm-cholelithiasis
Review USG
- Evidence of 7*4cm Liver Abscess noted in segment 5 of liver with 10-20% liquefaction
DIAGNOSIS:
LIVER ABSCESS in SEGMENT 5
PARTIALLY LIQUEFIED(10%- 20%)
CHOLELITHIASIS 6-7MM
TREATMENT:
- INJ.PIPTAZ 4.5G/IV/TID FOR 6 DAYS
- INJ METROGYL 500MG/IV/TID FOR 6 DAYS
- IVF - NS/RL @ 100ML/HR IV INFUSION
- INJ PANTOP 40MG/ IVIOD
- IN ZOFER 4MG/IV/SOS
- TAB ULTRACET PO/BD
- INJ OPTINEURON 1 AMP IN 100ML NS/IV/OVER 30MINS
- SYP.CREMAFFIN POHS 15ML
- INJ TRAMADOL 1 AMP IN 100ML NS/IV/OVER 30MINS SOS
- TAB OFLOXACIN 400 MG PO BD
- TAB METROGYL 500 MG PO TID
