1601006020 long case
Hall ticket no. 1601006020
GENERAL MEDICINE
FINAL PRACTICALS-LONG CASE
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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 ,continous associated with chills and rigor ,relieved on taking medication
No History of Nausea, Vomitings , Loose stools, Malena, 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 adequate
-His bowel movements are irregual 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 beedis/day since 30 yrs.
Family history:
-not significant
Treatment history:
-took medication in local hospital 6 months back for jaundice.
On General Examination:
- The patient is conscious,cohorent, 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:
Oral cavity : brown staining of teeth.
GASTROINTESTINAL EXAMINATION :
On 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.
-No hernial swellings with and without cough impulse
• Posterior abdominal wall,
No scars , swellings, pulsations
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 palable
-Abdominal girth is 84 cms
On Percussion,
Liver span -16cm
No shifting dullness,fluid thrill
On 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, Engroged 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 fermitus Decreased on Right side lower region
- Apex beat is palpable in 5th intercoastal 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
Infrascapular. Dull. . 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
• Interscapular. Normal. Normal
CVS
Normal S1 S2 heard
No murmurs
Apex beat felt on 5th intercostal space
CNS
No focal deficits seen
INVESTIGATIONS :
Complete blood picture
Liver function tests.
ECG
Rate : 100bpm
Regular
Low voltage QRS complexes in L2 , AvF , V1
P waves T waves not visible in AvL
Left axis deviation
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 Abcess with right side pleural effusion.
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