1601006187-- LONG CASE Final practical
HALL TICKET NO.: 1601006187
LONG CASE:
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A 61 year old gentleman ,shepherd by occupation came with complaints of pain in abdomen since 10 days and Fever since 2 days.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 10 days ago ,then he developed
1. Pain in abdomen
-from 10 days
-It is a diffuse type , insidious in onset , progressive, dragging associated with shortness of breath , it was non radiating, moderate pain with no diurnal variations , it was relieved by sleeping sideways
2. Fever
From 2 days ,Low grade ,continuous associated with chills and rigor ,relieved on taking medication.
No History of Nausea, Vomitings , Loose stools, flatulence,loss of weight , decreased urine output, dysuria.
PAST HISTORY:
-He had yellowish discoloration of eyes 6 months ago.
- No history of diabetes mellitus, hypertension, tuberculosis, epilepsy,asthma.
PERSONAL HISTORY:
• Mixed diet
• Appetite is adequate
• Bowel movements are irregular as he is constipated.
• 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, coherent and 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 per minute, regular, normal in volume and character.
- Blood pressure = 120/70 mm of Hg
- Respiratory rate = 22 cycles per minute.
- 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, Koilonychia ,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.
- Spleen , kidneys , urinary bladder are not palable
-Abdominal girth is 84 cms
On Percussion:
Liver span - 16 cms
No shifting dullness
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 symmetrical ,Elliptical
•Trachea appears to be Central
•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.
•No spinal deformities
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 cm 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 the 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:
Complete urine examination:
Liver function test:
Ultrasound Abdomen:
Aspiration of liver abcess
Pleural fluid examination:
Pleural tap:
Chest X-ray:
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
