Liver abscess
I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan
K.shirisha
Rollno;68
A 42 year old male patient occupation by paddy field worker by occupation brought to GM opd on 10/1/23.(2:30pm).with complaints of abdominal pain and fever since 3days
.shortness of breath since 2 days
Cough since 1 day
History of present illness;
The patient was apparently asymptomatic 3days ago. then he had fever with high grade
which was insidious in onset, gradually progressive.intermittent in nature and associated with chills and rigor and evening rise of temperature.
and was relieved on taking by medication which was prescribed by local rmp
C/O pain in right hypochondrium and epigastriumsince 3days.which was sudden in onset and gradually progressive nonradiatingit was dull aching type. No aggrevating and relieving factors. Not relieved on medication
Since on 10/1/23abdominal pain was severe with shortness of breath due to which he visited local rmp .and he was referred to our hospital.
C/O shortness of breath since 2days at rest
No aggrevating and relieving factors
C/Ocough with expectoration , mucoid in consistency
C/Ochest pain associated with cough
C/O loss of appetite since 3days
H/o binge alcohol intake fromJan 1 to Jan 5
No history of vomiting,loose stools,weight loss.,palpitations,pedal edema
No h/O outside food intake
Surgery referral notes:
Past history;
No history of similar complaints inthe past.
he is not a known case of diabetes, hypertension, tuberculosis, asthma and thyroid ,epilepsy disorders
Family history; insignificant
Personal history:
Appetite: decreased
Diet: mixed
Bowel and bladder: regular
Sleep: adequate
Alcoholic since 2 years
Bidismoker since 20 years
Toddy drinker
General examination;
Patient is conscious coherent cooperative
Pallor: absent
Icterus: absent
No cyanosis,clubbing, lymphadenopathy, edema
Vitals:
Temp: 100.8f
Bp: 100/70mmhg
HR: 82bpm
RR:20cpm
Spo2: 98%onRa
Grbs: 339mg/dl
systemic examination:
Per Abdomen:
Shape : scaphoid
Umbilicus; central
Movements ; normal
No visible pulsations,or engorged veins,no visible peristalsis
Skin over abdomen ; normal
Palpation :
Tenderness in right hypochondrium and epigastrium,local rise of temperature present
Hepatomegaly present with span of 15cms
No splenomegaly
Percussion;
Liver : dull note heared,liver span ;15cms
No shifting dullness or fluid thrills
Auscultation ; bowel sounds are heared
Respiratory system ;
Inspection;
Inspection of upper respiratory tract;
Oral cavity ; normal
Nose: no dns,polyp
Pharynx; normal
Lower respiratory tract;
Position of apex beat ; left 5ics 1cm medial to mid clavicular line
Symmetry of chest : symmetrical and elliptical
Movements of chest ; normal
Position of trachea ; midline
Bilateral air entry present
Palpation:
No tenderness over chest wall,no palpable added sounds,no palpable pleural rub
Percussion;
Dullnote heared
Auscultation: BAE+
Decreased air entry in RIAA,IMA,ISA
Crepts in heard in RIAA,IMA,IMA
Cardiovascular system;
S1,S2 heared, no murmurs
CNS:
HMF+
No focal neurological deficit
Provisional diagnosis:
Liver abscess . With Right pleural effusion with Denovo type2Dm
Investigations:
10/1/23
Hemogram:
HB: 14.2g/dl
TLC: 34,500
PC: 4.50 lakhs/mm3
Impression: Normocytic normochromic Anemia with leukocytosis
RBS: 375mg/dl
Urine for ketone bodies : negative
RFT:
Blood urea: 46mg/dl
Serum creatinine: 1.1
Na: 135
K: 5.2
Cl: 99
ICA: 0.88
FBS:252
Plbs:
Hba1c:7.1
LFT:
TB: 1.12
DB: 0.50
AST: 18
ALT: 19
ALP: 252
TP: 6.5
Albumin: 3.1
A/G: 0.93
ESR:
100
Mp: negative
Blood for mp strip test: negative
CUE:
Albumin: ++
Sugars: ++++
Pus cells: 4-6
Epithelial cells:3-6
On 16/1/23
Serum amylase:54
Serum lipase: 28
Chest xray
ECG:
Outside reports:
Treatment:
IV fluids NS/RL @ 100 ml/hour
Inj.magnex forte 1.5gm /iv/bd day2
Inj metrogyl 500 mg/iv/Tid
Inj pan 40mg/iv/od
Inj optineuron 1 amp in 100 ml Ns/Bd
Tab. Dolo 650 mg/po/Tid
Inj neomol 1gm/iv/sos ( if temp> 101F)
Inj HAI s/c /Tid according to grbs
11/1/23:
℅ pain in the right hypochondrium,
℅ sob
No fever spikes
O:
Patient was conscious ,coherent, cooperative
Vitals:
Temperature:Afebrile 98.7 F
Bp: 110/80 mmHg
HR: 83 BPM
RR:21cpm
Grbs:
8pm: 432mg/dl inj Hai 12u+ 6u nph
10pm: 332 inj 6u hai
12am: 189
2am: 207mg/dl
8am: 287
P/A: soft
Tenderness present in right hypochondrium, in suprapubic region
No guarding rigidity
Bowel sounds: heared
RS: BAE + no crepts
Decreased air entry on Rima, IAA,isa
Cvs: S2,S2+, no murmurs
CNS: No focal neurological deficit
Investigations:
FBS: 252
S.Urea:41
S creatinine: 0.8
Na: 134
K:5.2
Cl:96
ICa:0.92
Lipid profile:
Cholesterol:118
TG:361
HDL:37.9
LDL:88
A:
Liver abscess with Right pleural effusion
With Denovo type 2 DM
P:
IV fluids NS/RL @ 100 ml/hour
Inj.monocef 1gm /iv/bd day2
Inj metrogyl 500 mg/iv/Tid day 2
Inj pan 40mg/iv/od
Inj optineuron 1 amp in 100 ml Ns/Bd
Tab. Dolo 650 mg/po/Tid
Inj neomol 1gm/iv/sos ( if temp> 101F)
Inj HAI s/c /Tid according to grbs
14/1/23
Amc bed no:5
Unit 2
Dr.Aashitha sr
Dr .manasa pgy3
Dr. Hari priya , pgy2
Dr. Lohith pgy1
Dr.nithin pgy1
Dr.shirisha intern
Dr.vishal intern
Dr.shirisha intern
:
S
℅ pain in the right hypochondrium, ( resolved)
Fever last night ( relieved)
O:
Patient was conscious ,coherent, cooperative
Vitals:
Temperature:afebrile 98.6F
Bp: 120/80 mmHg
HR: 88BPM
RR:20cpm
Grbs:
8am: 124mg/dl inj Hai 4u+ 8u nph
10am: 171
2pm:160mg/dl inj hai 8u
4pm: 165mg/dl
8pm: 132inj hai 8u+ 6u nph
10 pm: 169mg/dl
2am: 127mg/dl
8am: 116mg/dl injhai 8u+nph 6u
I/O:3300ml/1100ml
P/A: soft
Tenderness in right hypochondrium
No guarding and rigidity
Bowel sounds: heared
RS: BAE + no crepts
Decreased air entry on Rima, IAA,isa
Cvs: S1,S2+, no murmurs
CNS: No focal neurological deficit
Investigations:
S.Urea:41
S creatinine: 0.8
Na: 134-137-138-138
K:5.2-4.3-4.3-4.5
Cl:96-97-97-99
ICa:0.92-0.71-0.75-0.85
Lft:
TB: 1.74
DB:0.42
AST:21
ALT:12
ALP:248
Tp: 5.9
Alb: 2.4
A/G:0.70
Hemogram:
HB:11.4-11.4-11.9
TLC:20,600-19900-21,400
PC:3.9 lakhs-7.2lakhs-4.5lakhs
A:
Liver abscess( hypoechoic) with Right pleural effusion
With Denovo type 2 DM
P:
IV fluids NS/RL @ 100 ml/hour
Inj.monocef 2gm /iv/bd day5
Inj metrogyl 750 mg/iv/Tid day 5
Inj pan 40mg/iv/od
Inj optineuron 1 amp in 100 ml Ns/Bd
Inj Thiamine 200mg in 100 mlNs /iv/Bd
Inj Hai s/c
8u -8u -8u
8am. 2pm. 8pm
Inj NPH s/c
6u. -. 6u
8am. 8pm
Tab. Dolo 650 mg/po/Tid
Inj Tramadol 1 amp in 100lNs/iv/sos
Inj neomol 1gm/iv/sos ( if temp> 101F)
Grbs 7 point profile monitering
Monitor vitals
15/1/23
S
℅ pain in the right hypochondrium,
Fever since last night
O:
Patient was conscious ,coherent, cooperative
Vitals:
Temperature:afebrile 98.6F
Bp: 120/80 mmHg
HR: 88BPM
RR:20cpm
Grbs:
8am: 116mg/dl inj Hai 8u+ 6u nph
10am: 122
2pm:118mg/dl inj hai 8u
4pm: 124mg/dl
8pm: 134inj hai 8u+ 6u nph
10 pm: 169mg/dl
2am: 127mg/dl
8am: 104mg/dl injhai 8u+nph 6u
I/O:3300ml/1100ml
P/A: soft
Tenderness in right hypochondrium
No guarding and rigidity
Bowel sounds: heared
RS: BAE + crepts in R ISA
Decreased air entry on Rima,
Cvs: S1,S2+, no murmurs
CNS: No focal neurological deficit
Investigations:
S.Urea:41
S creatinine: 0.8
Na: 134-137-138-138-137
K:5.2-4.3-4.3-4.5-4.2
Cl:96-97-97-99-101
ICa:0.92-0.71-0.75-0.85-0.86
Lft:
TB: 1.74
DB:0.42
AST:21
ALT:12
ALP:248
Tp: 5.9
Alb: 2.4
A/G:0.70
Hemogram:
HB:11.4-11.4-11.9-11.0
TLC:20,600-19900-21,400-24,300
PC:3.9 lakhs-7.2lakhs-4.5lakhs-5.2 lakhs
FBS: 252mg/dl
Plbs: 370mg/dl
Hba1c:7.1%
A:
Liver abscess( hypoechoic)
With Denovo type 2 DM
P:
IV fluids NS/RL @ 100 ml/hour
Inj.monocef 2gm /iv/bd day6
Inj metrogyl 750 mg/iv/Tid day 6
Inj pan 40mg/iv/od
Inj Thiamine 200mg in 100 mlNs /iv/Bd
Inj Hai s/c
8u -8u -8u
8am. 2pm. 8pm
Inj NPH s/c
6u. -. 6u
8am. 8pm
Tab. Dolo 650 mg/po/sos
Inj neomol 1gm/iv/sos ( if temp> 101F)
Grbs 7 point profile monitering
Monitor vitals
16/1/23
S
℅ pain in the right hypochondrium, ( decreasing)
Fever since last night
O:
Patient was conscious ,coherent, cooperative
Vitals:
Temperature:afebrile 98.6F
Bp: 110/70 mmHg
HR: 84BPM
RR:20cpm
Grbs:
8am: 104mg/dl inj Hai 8u+ 6u nph
10am: 210
2pm:226mg/dl inj hai 8u
4pm: 124mg/dl
8pm: 92inj hai 8u+ 6u nph
10 pm: 169mg/dl
2am: 230mg/dl
8am: 102mg/dl injhai 8u+nph 6u
I/O:3500ml/1000ml
P/A: soft
Tenderness in right hypochondrium
No guarding and rigidity
Bowel sounds: heared
RS: BAE + crepts in R ISA
Decreased air entry on Rima,
Cvs: S1,S2+, no murmurs
CNS: No focal neurological deficit
Investigations:
S.Urea:41
S creatinine: 0.8
Na: 134-137-138-138-137
K:5.2-4.3-4.3-4.5-4.2
Cl:96-97-97-99-101
ICa:0.92-0.71-0.75-0.85-0.86
Lft:
TB: 1.74
DB:0.42
AST:21
ALT:12
ALP:248
Tp: 5.9
Alb: 2.4
A/G:0.70
Hemogram:
HB:11.4-11.4-11.9-11.0-10.9
TLC:20,600-19900-21,400-24,300-19,400
PC:3.9 lakhs-7.2lakhs-4.5lakhs-5.2 lakhs-5.71 lakhs
FBS: 252mg/dl
Plbs: 370mg/dl
Hba1c:7.1%
A:
Liver abscess( hypoechoic)
With Denovo type 2 DM
P:
IV fluids NS/RL @ 100 ml/hour
Inj. Piptaz 4.5 gm /iv/Tid d2
Inj metrogyl 750 mg/iv/Tid day 7
Inj pan 40mg/iv/od
Inj Thiamine 200mg in 100 mlNs /iv/Bd
Inj Hai s/c
8u -8u -8u
8am. 2pm. 8pm
Inj NPH s/c
6u. -. 6u
8am. 8pm
Tab. Dolo 650 mg/po/sos
Inj neomol 1gm/iv/sos ( if temp> 101F)
Grbs 7 point profile monitering
Monitor vitals
On 17/1/23
℅ pain in the right hypochondrium, suprapubic region ( decreasing)
Fever since last night
O:
Patient was conscious ,coherent, cooperative
Vitals:
Temperature:febrile 101.8f
Bp: 120/70mmHg
HR: 84BPM
RR:20cpm
Grbs:
8am: 162mg/dl inj Hai 8u+ 6u nph
10am: 210
12pm:164mg/dl inj hai 8u
2pm: 85mg/dl
4pm:165mg/dl
8pm: 112inj hai 8u+ 6u nph
10 pm: 131mg/dl
2am: 148mg/dl
8am: 137mg/dl injhai 8u+nph 6u
I/O:3100ml/1250ml
P/A: soft
Non tender
No guarding and rigidity
Bowel sounds: heared
RS: BAE + crepts in R ISA
Decreased air entry on Rima,
Cvs: S1,S2+, no murmurs
CNS: No focal neurological deficit
Investigations:
S.Urea:41-13
S creatinine: 0.8-0.9
Na: 134-137-138-138-137-134
K:5.2-4.3-4.3-4.5-4.2-4.6
Cl:96-97-97-99-101-98
ICa:0.92-0.71-0.75-0.85-0.86
Lft:
TB: 1.74
DB:0.42
AST:21
ALT:12
ALP:248
Tp: 5.9
Alb: 2.4
A/G:0.70
Hemogram:
HB:11.4-11.4-11.9-11.0-10.9-8.5
TLC:20,600-19900-21,400-24,300-19,400-17k
PC:3.9 lakhs-7.2lakhs-4.5lakhs-5.2 lakhs-5.71 lakhs-7 lakhs
FBS: 252mg/dl
Plbs: 370mg/dl
Hba1c:7.1%
A:
Liver abscess( hypoechoic)
With Denovo type 2 DM
P:
IV fluids NS/RL @ 100 ml/hour
Inj. Piptaz 4.5 gm /iv/Tid d3
Inj metrogyl 750 mg/iv/Tid day 8
Inj pan 40mg/iv/od
Inj Thiamine 200mg in 100 mlNs /iv/Bd
Inj Hai s/c
8u -8u -8u
8am. 2pm. 8pm
Inj NPH s/c
6u. -. 6u
8am. 8pm
Tab. Dolo 650 mg/po/sos
Inj neomol 1gm/iv/sos ( if temp> 101F)
Grbs 7 point profile monitering
Monitor vitals
18/1/23
℅ pain in the right hypochondrium, suprapubic region ( decreasing)
Fever since last night
O:
Patient was conscious ,coherent, cooperative
Vitals:
Temperature:febrile 101.8f
Bp: 120/70mmHg
HR: 84BPM
RR:20cpm
Grbs:
8am: 137mg/dl inj Hai 8u+ 6u nph
10am: 232
12pm:164mg/dl inj hai 8u
2pm: 139mg/dl
4pm:165mg/dl
8pm: 114inj hai 8u+ 6u nph
10 pm: 114mg/dl
2am: 309mg/dl
8am: 115mg/dl injhai 8u+nph 6u
I/O:3800ml/1550ml
P/A: soft
Non tender
No guarding and rigidity
Bowel sounds: heared
RS: BAE +
Decreased air entry on Rima,
Cvs: S1,S2+, no murmurs
CNS: No focal neurological deficit
Investigations:
S.Urea:41-13
S creatinine: 0.8-0.9
Na: 134-137-138-138-137-134
K:5.2-4.3-4.3-4.5-4.2-4.6
Cl:96-97-97-99-101-98
ICa:0.92-0.71-0.75-0.85-0.86
Lft:
TB: 1.74
DB:0.42
AST:21
ALT:12
ALP:248
Tp: 5.9
Alb: 2.4
A/G:0.70
Hemogram:
HB:11.4-11.4-11.9-11.0-10.9-8.5-10
TLC:20,600-19900-21,400-24,300-19,400-17k-17600
PC:3.9 lakhs-7.2lakhs-4.5lakhs-5.2 lakhs-5.71 lakhs-7 lakhs-6.2lakhs
FBS: 252mg/dl
Plbs: 370mg/dl
Hba1c:7.1%
A:
Liver abscess( hypoechoic)
With Denovo type 2 DM
P:
IV fluids NS/RL @ 100 ml/hour
Inj. Piperacillin + Tazobactem 4.5 gm /iv/Tid d4
Inj pantoprazole 40mg/iv/od
Inj Thiamine 200mg in 100 mlNs /iv/Bd
Inj Hai s/c
8u -8u -8u
8am. 2pm. 8pm
Inj NPH s/c
6u. -. 6u
8am. 8pm
Tab. Paracetamol 650 mg/po/sos
Inj paracetamol 1gm/iv/sos ( if temp> 101F)
Grbs 7 point profile monitering
Monitor vitals
Brief course in the hospital:
Day-1: patient presented to the opd with pain in right hypochondrium and high grade fever , cough, and shortness of breath and the grbs was 339 at the time of presentation and was kept on iv antibiotics for hiS fever and inj huam. Actrapid insulin started as his sugat levels were high and. Ultrasound abdomen was done and it showed well defined heteroechoic cystic lesion With no internal vascularity in left lobe of liver and liver abscess was found on ultrasound and inj metronidazole was started and as he is alcoholic inj Thiamine was started
Day-2: pain abdomen and fever weren't subsided and continued on same antibiotics and review USG was done for liver abscess and it showed a 4.2x 4.1 cms well defined hypoechoic lesion noted in cauadate lobe of liver
With thick internal echoes and no vascularity and surgery consultation was taken and advised pig tail catheter drainage once the abscess was liquified and serum amylase,lipase were send and are normal
Day-3: As the patient sob is not relieved and repeat chest x ray was done and it showed with CLEAR lung fieldsand USG chest was done and it showed b/l. Mild pleural effusion
Day-4: pain in the right hypochondrium decreasing and no fever spikes were present and there is a mild tendeness in right hypochondrium
Day-5: pain in hypochondrium decreased and no fever spikes were present.tendernessin right hypochondrium decreasing and blood and urine cultures has no growth
Day 6: Review abdomen was done it was found to be having 4.1x4.0 cms hypoechoic lesion noted in cauadate lobe of liver with greater than 60% liquefaction
And no vascularity and 22x28mm hypoechoic lesion noted in 5and 6 segment of liver with no vascularity and loculated ascitis.
Day-7:
Review surgery opinion was taken for liver abscess and advised serum amylase, lipase and are normal and advised to continue the same treatment
Day-8: As his fever got subsided and pain abdomen got relieved and hai sugar levels were under controlAnd the injectable firm of insulin was converted into oral hypoglycemic agents and the rest symptomatic treatment was continues
Day-9: pateint is hemodynamically stabel and the patient is get discharged with HB: 10.4,Tlc:16,400,platelet count:
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