General Medicine Case history-1

 GM Case history -1 


July 9th 2021 


Date of admission -  05-08-2021 


A 26yr- old -man  presented with Fever from  , Blood tinged Cough , Vomitings (Blood tinged) , Dyspnea on exertion  from past 2 months .

 

History of Present illness 


Patient was apparently asymptomatic 3 months back, then he has been having vomitings 3 episodes per day containing food particles and blood . 

Consulted to the nearest hospital but was mis- diagnosed as  TB and took the course for Tuberculosis around 20 days . 

Then shifted to  the AMC unit in another hospital .


Dark colored stool from 2 weeks . 

Abdominal pain . 


History of Past illnes - 


C/o loss of appetite  over 2 months 

Loss of weight over 2 months 


Not a known case of HTN, CAD, Asthma, TB, Epilepsy, Thyroid disorders.

No history of surgeries and blood transfusions in the past.


 Personal History 


He has been consuming alcohol for the past 2 years.  Recently consumed beers . 



FAMILY HISTORY -


No history of DM, hypertension, CVA, CAD, Asthma, Thyroid disorders in the family.


GENERAL EXAMINATION -


Patient is conscious, coherent, co-operative.

There is  no icterus and pedal edema.

Pallor  was noticed . 

cyanosis, clubbing, koilonychia, lymphadenopathy.


VITALS -

Temperature- 98.6 F 

Pulse rate- 98 bpm

Respiratory Rate- 20 cpm

BP-110/70 mmHg 

SPO2 at room air- 98% 

GRBS 202 mg/dl


SYSTEMIC EXAMINATION -


CARDIOVASCULAR SYSTEM:

Inspection:


Tactile vocal fremitus- Symmetrical 

Chest wall is bilaterally symmetrical.

No precordial bulge

No visible pulsations, engorged veins, scars, sinuses


Palpation:

JVP: normal


Auscutation:

S1, S2 heard 

No murmurs heard 


 RESPIRATORY SYSTEM-

Position of trachea: central

Bilateral air entry +

Normal vesicular breath sounds - heard

No added sounds.


PER ABDOMEN:

Abdomen is distended, hard and tender in Epigastric , Right hypochondriac region. 


Bowel sounds heard.



CENTRAL NERVOUS SYSTEM:


Patient is Conscious 

Speech: normal

No signs of Meningeal irritation

No neck stiffness 

Motor & sensory system: normal

Reflexes: present

Cranial nerves: intact


Provisional Diagnosis 


Cirrhosis of liver ? 

Appendicitis ? 

Liver abscess ? 


Further  tests done - 

ECG ,2D echo 

USG -abdomen ( for liver and spleen size ) 

Hemogram , RFT and LFT , CXR-PA , 

 

Specimens collected - stool , blood , urine samples . 


Report




Final Diagnosis - 

Liver mass / abscess with decreased evaluation . 


Treatment 


Day 1 

IVF ( 20 NS @ 75ml/ hr) 

        

IVF  1 amp Optineuron

Inj Augmentin  1.2g/ IV / BD 

Inj  Pantop 40mg IV /OD 

Inj Zofer 4mg IV /TID 

Tab Dolo 650 mg ( SOS) 

Syp Ambroxyl 10 ml ,TID 



Day 2 

Inj Metrogyl  TID

Inj  Zofer ,TID

IV fluid -NS ,TID 

Inj monocef  1g /BD 

Syp Ambroxyl 10 ml ,TID 


Day 3 & 4 


Inj monocef  1g BD 

Inj  zofer 4mg/IV TID 

Inj  Pantop 40mg IV /OD

Inj 1 amp Optineuron IV/ OD

Inj Metrogyl 100ml /IV  TID 

Tab .Dolo 650mg (SOS) 

Tab.Paromomycin 500mg . 


Final update 


The patient is diagnosed with liver mass after evaluation of reports and scans .

Treatment is conservative .



Why the patient had symptoms of blood coughs? 


What are the other GIT  diseases where  blood cough is indicated ?


Initial differentiation between symptoms of ulcer and an abscess in liver? 


How common is liver abscess is seen ?


What size liver abscess should be drained?


How can you tell the difference between amoebic and pyogenic liver abscess?

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