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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
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 ,continous 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, Koilobyhia ,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 









ABDOMEN X-RAY





ECG



 Rate : 100bpm
Regular
 Low voltage QRS complexes in L2 , AvF , V1
P waves T waves not visible in AvL



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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