CASE PRESENTATION DR VIVEK TIWARI 3_e0d66e00-44db-402f-aef2-8e7316475854.pptx

Case presentation

1. CLINICAL CASE PRESENTATION PRESENTED BY: DR. VIVEK TIWARI JUNIOR RESIDENT I DEPARTMENT OF SHALYA TANTRA

2. Patient Name – MR.X Age –72 yr Gender – Male Marital Status – Married Ward /Bed No – Shalya / M22 Occupation - Labour

3. Chief Complaints: A 72 year old gentleman complaining of Pain in Right Upper abdomen since 6 -7 days . Fever with chills (on/off) x 6-7 days A/W – Reduced Appetite & G eneralized weakness x 7 days

4. HISTORY OF PRESENT ILLNESS: According to the patient, he was apparently asymptomatic before 6 – 7 days . Then he noticed Pain in Rt. Upper abdomen Initially pain was in whole abdomen later on it confined to right upper abdomen and epigastric region. Gradual,dull type,moderate Not a/w nausea and vomiting. There was abdominal distension also. No history of loose stool.

5. Fever for 6-7 days Intermittent,max temp 102f Associated with chills Subsided with taking oral antipyretics The Patient had similar complaint one month back and he had been diagnosed as pyogenic liver abcess for which 950 ml of pus aspirated through USG Guided aspiration after that he got temporarily relief but since 7 days he presented with similar complain as described above so for better management he came to SSH, BHU .

6. HISTORY OF PAST ILLNESS: No history of Diabetes Mellitus-2,TB, Bronchial Asthma, Thyroidism , COPD, HTN . No history of Any major Accidental trauma. No history of Drug allergen Known . No history of previous surgery, Blood transfusions.

7. FAMILY HISTORY: No significant family history.

8. PERSONAL HISTORY : Diet : Veg App : Reduced Bowel : incomplete evacuation of bowel ( 2-3 times/day ) Micturition: Regular (5-6 times/ day) Sleep : Reduced (4-5 hours/day) Addiction: Tabacoo Chewing – 20 years

9. GENERAL PHYSICAL EXAMINATION : Temperature = febrile (100.6 f) General condition = Fair Pallor = Present Icterus = Absent Cyanosis = Absent Clubbing = Absent Lymph node = not palpable Oedema = Absent BP = 118/86 mmHg PR =88bpm RR= 16/min

10. SYSTEMIC EXAMINATION: Cardiovascular system Central nervous system Respiratory system Gastrointestinal System

11. SYSTEMIC EXAMINATION: CARDIOVASCULAR SYSTEM: Both S 1 S 2 – heard Normally No added sounds heard. RESPIRATORY SYSTEM: Trachea is Centrally Placed Bilateral equal Air entry Bilateral equal Chest Expansion Bronchovesicular sound heard Normal

12. CNS EXAMINATION: Patient is conscious and well oriented to person, place and time. Obeys simple verbal commands.

13. GASTROINTESTINAL SYSTEM: Skin over abdomen –Normal in appearance Umbilicus is centrally placed and inverted No any visible vein seen

14. LOCAL EXAMINATION- A - Inspection(per Abdomen) skin over abdomen –Normal in appearance Umbilicus is centrally placed and inverted No any visible vein seen no any scar mark present Abdomen is distended

15. B)PALPATION- Temperature - Normal Tenderness present in right hypochondrium. Murphys sign Negative Boas sign No palpable mass or any organomegaly

16. C) Percussion – Dull note over epigastric and Rt. Hypochondrium rest tympanic note D )Auscultation Bowel sound(1-2time/min)

17. SUMMARY A 72 year old male patient labour by occupation presented in our opd with complains of Fever with chills & Pain in Rt. Upper quadrant of abdomen since 6 -7 days which was iniatially in whole abdomen later on it confined to right Hypochondrium and epigastric region which was dull in nature a / w reduced appetite and generalized weakness. Pain was not a/w vomiting with no relieving factors.

18. PROVISIONAL DIAGNOSIS Liver abscess Points in favour – fever Site and nature of pain General condition of patient

19. DIFFERENTIAL DIAGNOSIS Viral Hepatitis. Cholecystitis. Right lower lobe pneumonia Acute pancreatitis Right uretric colic

20. Reason to exclude viral Hepatitis S ign and symptoms Fever Fatigue Anorexia Nausea,vomiting Abdominal Pain clinical jaundice Investigations- LFT-increased bilirubin and transaminases Antibody titre

21. Reason to exclude Cholecystitis Cholecystitis Dull aching P ain in RUQ Bloating,Nausea vomiting Upper abdominal guarding

22. Reason to exclude Right lower lobe pneumonia - S ign and symptoms Abdominal tenderness minimal High grade fever Loss of appetite and fatigue Shortness of breath,Cough Chest examination- Altered breath sound Investigations- Blood-leukocytosis, pancytopenia Chest X-ray CT chest

23. Reason to exclude Acute Pancreatitis Si gn and symptoms- Upper abdominal pain Pain radiates to back Abdominal tenderness Fever Rapid pulse Nausea /vomiting Investigations- Serum Amylase and lipase will be raised

24. Reason to exclude Right Uretric Colic Sign and symptoms- Pain is colicky in nature which often refer to genitalia. Fever with chills Painful and burning micturation,increased frequency Hematuria In ureteric stones abdomen is soft and non tendor . Investigations- Urine culture and sensitivity

25. Investigations CBC LFT RFT USG (w/A)( accuracy 80-90% in diagnosing abscess >2cm in diameter ) CT Abdomen( can detect upto 0.5cm intrahepatic collection ) Chest X-ray PA view-may show elevation of hemidiaphragm .

26. CBC HB- 8.9 gm/dl WBC- 10290/dl PLT- 243000/dl RBC- 2,78,000/dl

27. LFT SGPT/OT- 35.6/19.5 U/L Bill Direct – 0.4 mg/dl Bill Indirect - .1 mg/dl Bill Total -.5 mg/dl Ser. ALP – 382.3 U/L Ser. Protien – 7.7 g/dl Ser Albumin -2.4 g/dl

28. RFT -WNL RBS -84 mg/dl

29. MANAGEMENT Antibiotic therapy Percutaneous Aspiration & Drainage Surgical management

30. Pyogenic liver abscess IV antibiotic is given (given for 6-8 weeks) Aminoglycosides+Metronidazole 3 rd gen. cephalosporins+metronidazole Amoebic Liver abscess Metronidazole tab 750mg TDS (7-10 days) Metronidazole IV 500mg TID Nitroimidazoles

31. Percutaneous Aspiration & Drainage Large abscess size >10cm if there is no response from antibiotic therapy . High risk of rupture of abscess Large abscess of left lobe Conditions where drugs can’t be used

32. Indication for Surgery Even after repeated aspiration or percutaneous drainage abscess cavity fills again. Thick pus,multiloculated abscess Left lobe abscess Ruptured,multiple abscess

33. THANK YOU