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?

Comments

Post a Comment

Popular posts from this blog

General Medicine Prefinal Exam Case

Image
  This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.  Here, we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. Date of Admission : 19-12-2021 A 48-YEAR-OLD MAN WITH GRADE IV SOB. A 48 year-old man came to the hospital with chief complaints of p edal edema since 1 month,s hortness of breath which aggravated since 2 hours,p roductive cough since 2-3 days.  History of present illness : The patient was apparently asymptomatic 1 month ago when he noticed swelling in both his legs which was gradually progressive, extending to his knees.   H istory of   increased shortness of breath since 1 day which aggravated to Grade 4 SOB since 2 hours, associated with orthopnea and PND.  H/o Productive...
Read more

GM Case history -2

Image
 GM Case history -2  August 23rd Date of admission  - 22-01- 2021  A 22y- old - woman  presented with  blurry vision .   History of Present illness  The patient was apparently asymptomatic  8months back ,then she had blurry vision for a week  and Hypertensive ( BP 220/70mm Hg)  .Consulted to an Opthomologist , found a clot in the eye , suggested a complete body scan .  History of Past illnes -  No history of Weight loss. Not a known case of HTN, CAD, Asthma, TB, Epilepsy, Thyroid disorders. No history of surgeries and blood transfusions in the past.  Personal History  No history of consumption of alcohol. History of low /minimum intake of water . FAMILY HISTORY - No history of DM, hypertension, CVA, CAD, Asthma, Renal disorders. Thyroid disorders in the family. GENERAL EXAMINATION - Patient is conscious, coherent, co-operative. There is  no icterus. No pallor ,cyanosis, clubbing, koilonychia or lymphadenopat...
Read more

Internal Assesment -2

Image
 2) Acute pancreatitis  3)Dengue fever  4) Cushing Syndorme  5) Mandibular advancement device  6)Cardiogenic Pulmonary edema 7)Rheumatoid Arthritis  8) Leptospirosis  9) Heart failure  10) Ascites  11) Pyrexia of unknown origin  12)Drug induced liver injury  13) Evaluation of backache  14)Renal artery stenosis  15) Acute Kidney injury  20) Iron deficiency anemia
Read more