Cholelithiasis with Liver Abscess
9/03/22
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Sanidha Singh
Roll no.- 206
A 29 year old female, housewife from Bengal
CHIEF COMPLAINTS:
The patient came to GM OP on 09/03/22 with complaints of pain abdomen since 6 months
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 9 months back then she developed headache associated with fainting during her second trimester and had 4-5 episodes until term. The doctor prescribed her medicine (not known to the patient) for flatulence and asked her to eat properly.
Patient started presenting with right upper quadrant pain 6 months back after 10-12 days of normal delivery of her second child.
The patient developed pain in the Right Hypochondriac region which was dragging type and 3 month back started radiating to the back which aggravated on eating spicy/ fatty food and relieved on medication. Attack of pain is irregular & was only observed after eating.
10-12 days after the delivery the patient again consulted the same doctor and diagnosed it for flatulence & prescribed her some other medicine (which the patient said is Tab.Drotin M) which she took twice a day for 3 months.
The patient noticed that the pain got worse on eating spicy/ fatty food & then after taking medicines prescribed by the doctor she would get burps and the pain subsided.
On days when the pain was severe she would make attempts to get relief by drinking plenty of water to induce vomiting & the pain subsided and the patient felt better.
On 21/02/22 the patient went to doctor with excruciating pain where after performing an USG she was diagnosed with cholelithiasis with liver abscess. She was put on the medication and was asked to follow up after 10 days.
3/03/22 she was asked to get operated but the patients mother denied seeing the patients health and was referred to our hospital.
H/o vomiting 1 week back
H/o fever especially during nights approx 2 times in last 3 months associated with fainting & chills. Last episode of fever 10-15 days back. Fever lasting for 1-2 days and relieved on medication.
H/o constipation 2-3 times/ week
PAST HISTORY:
No h/o DM, HTN, Thyroid, epilepsy, TB, leprosy
FAMILY HISTORY: NAD
PERSONAL HISTORY:
Diet- Mixed
Appetite- Reduced
Sleep- Adequate
Bowel & bladder- bowel movement was irregular
GENERAL EXAMINATION:
Pallor-present
Icterus-absent
Clubbing-absent
Cyanosis-absent
Edema-absent
Lymphadenopathy-absent
VITALS:
Temp-98.5
Pulse-99bpm
RR-18cpm
BP-110/90mmHg
Spo2-99%
GRBS-115mg%
TREATMENT HISTORY:
1. Tab. Drotin M
2. Tab. Metrogyl 400
3. Tab. Vitalvit Gold
4. Tab. Pantocid - IT
5. Tab. Zentel 400
INVESTIGATION:
USG REPORT on 9/03/22
Liver abscess (+)
Contracted gall bladder due to fasting
Pt asked to come again tomorrow morning on empty stomach
USG REPORTS ON 10/03/22:
FINDINGS:
• E/o Multiple tiny calculi in contracted gall bladder largest (M) 4-5 mm
• E/o 3.1X2.4 cm hypoechoic lesion in segment VI g liver & no internal vasularity & mild perilesional edema.
IMPRESSION:
• Cholelithiasis (review again in fasting state)
• Liver abscess in segment VI g liver with 20-30% liquefaction
ECG:
HEMOGRAM :
Hb- 10.9
TLC- 5900
Lymphocyte- 43
PCV- 33.8
MCV- 77.7
MCH- 25.1
PLT- 2.77
CUE:
ALB- Trace
Sugar- Nil
Pus cells- 2-4
Epithelial cells- 2-3
Provisional diagnosis:
Cholelithiasis with liver abscess
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