Dr.

Farhana Sharmeen Moon

Intern Doctor
Medicine Unit II
Sylhet MAG Osmani Medical College
Particulars of the patient

Name: Salek Miah

Age: 45 years
Sex: Male
Present Address: Moghlabazar,Sylhet
Marital Status: Married
Occupation: Farmer
Religion: Islam
Date of admission:
Date of examination:
Chief Complaints

Fever for 15 days.
Pain in the right upper abdomen for same duration
History of present illness

According to the statement of the patient he was reasonably well 15 days
back.Since then he had been suffering from high grade remittent fever which
present throughout the day and associated with chills and rigor and relieved by
taking antipyretic.Patient could not mention highest recorded temperature.He
also complaints of pain in right upper abdomen for same duration which is dull
aching in nature,gradually increasing in severity,persist through the entire day
with no radiation and no aggravating or relieving factor.
On query , he mentioned that he had loss of apetite,malaise but no significant
weight loss.His bowel & bladder habit was not altered.
He gave no history of loose motion,passage of blood mixed stool,abdominal
distension,yellow colouration of skin and urine,cough,chest pain,right lower
abdominal pain,blood transfusion,parenteral drug abuse
History of past illness

He had no history of Diabetes mellitus , Hypertension, Bronchial
asthma.
No other significant medical or surgical history
Treatment history

He had been taking anti pyretic and anti ulcerant from local doctors.
Family History

He has two children , wife, and his father in his family
None of his family member suffered from such type of illness
All are in good health
Personal History

He was a smoker of 10 pack years & used to take betel leaves and nuts.
No history of extramarital exposure
He is a farmer and sells vegetable in local market
Socioeconomic history

He came from a low socio-economic background.
He lives in pacca house and has provision of taking well sanitation and
tubewell water.
Immunization History

He could not mention about vaccination
General examination

Appearance: ill looking

Body built: below average
Decubitus: on choice
Cooperation: cooperative
Anemia: mild
Jaundice: absent
Cyanosis: absent
Clubbing: absent
Cont..

Koilonychia: absent

Leukonychia: absent
Edema: absent
Dehydration: absent
Pulse: 92 b/min
Blood pressure: 130/70 mm Hg
Temperature: 101 F
Cont..

Respiratory rate: 22 breath/min

Lymph node: not palpable
Thyroid: not enlarged
JVP: not raised
Skin survey: normal
Systemic examination:
Alimentary System

Oral cavity: Normal

Abdomen:
Inspection:
Shape of the abdomen: fullness present in right hypochondriac region
Flanks:Not full
Umblicus: Centrally placed and inverted
Movement with respiration: Restricted in upper part of abdomen
No visible peristalsis,no engorged vein,no visible pulsation
Palpation:
Superficial palpation: Tenderness present in right hypochondriac region
Muscle guard: absent
Cont

Deep palpation:

Liver:Liver is palapable 3 cm from the right costal margin in right mid-clavicular
line,tender,has smooth surface,sharp margin,firm in consistency.Upper border of liver
dullness is in the right 5th intercostal space.
Spleen: Not palpable
Kidneys: Not palpable or ballotable
Percussion:
Percussion note: Tympanic.
Shifting dullness: Absent
Auscultation:
Bowel sound: Present
No hepatic Bruit
 Respiratory System:
Inspection:
Shape of the chest: normal
Movement of the chest symmetrical
Respiratory rate: 22 breath/ min
No visible apical impulse, engorged blood vessel

Palpation:
Trachea -centrally placed
Apex beat- in left 5th ICS
Chest expansion : normal
Vocal fremitus: normal
Percussion: Resonant on both side
Auscultation: Breath sound vesicular
No added sound
Vocal resonance - normal
Cardiovascular System

Precordium examination:

Inspection:
Size & shape: Normal
No visible apex beat
No visible engorged vein
Palpation:
Apex beat:Position of apex beat in left 5th intercostal space 9 cm from midline
No thrill, No parasternal heave
Auscultation:
Heart sound: Normal in all four auscultatory areas
Murmurs : Absent
Nervous system

Higher psychic function: normal

Cranial nerves: intact
Sensory and Motor nerve examination: normal
Neck rigidity: absent
Kernigs sign: absent

Systemic examination of other systems reveals no
abnormality
Salient feature

Salek Miah,45 years old,smoker,farmer,hailing from
moghlabazar,Sylhet,admitted to SOMCH with complaints of high grade fever
associated with chills and rigor and relieved by taking antipyretic. He also
complaints of pain in right upper abdomen for same duration which is dull
aching in nature,gradually increasing in severity with no radiation and no
aggravating or relieving factor. He had loss of apetite,malaise but no history of
loose motion,passage of blood mixed stool,abdominal distension,yellow
colouration of skin and urine.Patient is non diabeteic,non asthmatic,non
hypertensive.

On general examination he was mildly anaemic but jaundice,clubbing
koilonichia ,leukonychia was absent.His pulse 92/min, blood presser 130/


Provisional Diagnosis??

 Acute Viral Hepatitis
Hepatocellular Carcinoma
Investigation

Complete blood count

HB%-9.4g/dl
WBC-17,600/cmm
RBC-5.46 million/cmm
Platelet-543000/l
ESR-20mm in 1st hour
Neutrophil-87.9%
Lymphocyte-8.2%
Monocyte-3.6%
Eosinophil-0.3%
Basophil-0%
Cont..

Ultrasonogram of whole abdomen:

Large hypoechoic SOL noted in left lobe of liver
Comment-SOL in Liver-Abscess
S.Bilirubin-2.41mg/dl
S.ALT-49 U/l
S.Creatinine-1.03mg/dl
S.Electrolyte:Na+ 133.5mmol/l K+3.67mmol/l
Cl- 97.6 mmol/l
Cont

USG Guided Aspiration: Huge amount of Pus is aspirated
Colour:Chocolate colour( Anchovy sauce)
Pus is sent for Gram stain & Culture Sensevity

Pus for Gram stain & AFB: Shows no organism

Treatment

Bed rest

Diet-Normal
Inj Ampicillin 1gm
Inj Gentamicin 80mg
Inj Metronidazole 500mg
Tab paracetamol 500mg
Cap omeprazole 20mg
Napa Suppositery -SOS